Signatures
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I reviewed the Notice of Privacy Practices and that a copy has
been made available to me upon request.
INSURANCE AUTHORIZATION
I authorize any holder of medical information about me to release to Centers for
Medicare/Medicaid Services or my insurance companies any information needed to
determine these benefits or the benefits payable for related services. I also
authorize payment of insurance benefits, otherwise payable to me, directly to Master
Eye Associates (TAX ID 87-1463611) for services they furnish. I understand I am
ultimately responsible for the payment of fees to Master Eye Associates.
FINANCIAL POLICY AGREEMENT
Payment is due at the time services are rendered. We are required by law to collect
all co-payments, co-insurance and deductibles and we will collect those at the time
of your visit. We will file with your insurance company on your behalf at no charge
to you unless you advise us otherwise. Although we will make every effort to collect
from your insurance company, you are ultimately responsible for the payment of your
fees in full. Even pre-authorization from your insurance company does not guarantee
payment of fees. A credit card pre-authorization (see below) for any unpaid balance
is required if charges are filed with your insurance or if the full fee is not
collected at the time of visit.
A service fee is charged for all returned checks and/or credit card chargebacks. A
rebilling fee will be added to every invoice sent if we are not able to use the
credit card provided to us for the pre-authorized payment. You will also be
responsible for the costs of fees charged by attorneys or a collection agency for
the cost of collection if such action is taken because your bill is unpaid for over
90 days from the date of service.
PRE-AUTHORIZED PAYMENT AGREEMENT
We bill your insurance company on your behalf at no cost to you, but do not provide
direct patient billing service. Therefore, if you are using insurance to pay for our
service, we require guaranteed payments by a VISA or MasterCard. We are accredited
users of the VISA and MasterCard Healthcare Program, which secures our patient's
account information anonymously on an encrypted offsite server. In the case of
insurance non-payment, your time is saved by using this convenient collection of
owed amounts from this secured account information.
I authorize Master Eye Associates ("MEA") to keep my signature on file and to charge
my MasterCard or VISA the balance of charges not paid by my insurance (not to exceed
$400 and typically charged 60-180 days after the office visit) for all professional
services during the next 12 months. I understand this authorization is valid for one
year unless I cancel by written notice to MEA. I assign my insurance benefits to
MEA.
I understand and agree with the Insurance Authorization, Financial Policy &
Pre-Authorization Payment.