Our Financial Policy.
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We are committed to providing you with the best
possible care, and we are pleased to discuss our professional fees with you at
any time. Your clear understanding of our Financial Policy is important to our
Professional relationship. Please ask if you have any questions about our fees,
Financial Policy, or your responsibility.
All patients must complete our "Patient Information Form" before seeing the
doctor.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE.
WE ACCEPT CASH, CHECKS, MASTER CARD, VISA, AMERICAN EXPRESS
& DISCOVER CARD.
Eyeglasses & Contact Lenses
Prior to ordering you must pay 50% down and the balance will be due at the time
you receive them.
Adult Patients
Adult patients are responsible for full payment at time of service unless we
are contracted with your insurance company.
Minors Accompanied by an Adult
The adult accompanying a minor, and his/her parents (or guardians), are
responsible for full payment at time of service, unless we are contracted with
your insurance company.
Unaccompanied Minors
The parents (or guardians) are responsible for full payment, unless we are
contracted with your insurance company. Non-emergency treatment will be denied
unless charges are paid by cash or check at this time of service.
Regarding Insurance
If you have insurance, we will help you receive the maximum benefits. We bill
contracted insurance companies only, however, we will furnish you with a
receipt with information your insurance company requires.
If your insurance company has not paid the FULL BALANCE within 45 days, you
have 15 days to pay the balance. If your insurance company pays more than the
balance due we will send a refund check to you immediately.
Insurance is a contract between you and your insurance company. We are NOT a
party to this contract in most cases. (We will inform you if we are a party to
your insurance contract and will handle your claims according to our agreement
with the insurance company, if one exists.) We file insurance claims as a
courtesy to our patients. We will not become involved in disputes between you
and your insurance company regarding deductibles, co-payments, covered charges,
secondary insurance, "usual and customary" charges, etc., other than to supply
factual information as necessary. YOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF
YOUR ACCOUNT.
Medicare / AHCCCS / Champus / Worker's Compensation / Senior Care HMO'S
If you are covered by Medicare, AHCCCS, Champus, Worker's Compensation, or any
other government-sponsored program, please discuss your payment situation with
our office staff prior to date of service.
THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICY PLEASE LET US KNOW IF YOU HAVE
ANY QUESTIONS OR CONCERNS.
RESPONSIBLE PARTY SIGNATURE__________________________ DATE__________
PRINTABLE VERSION
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