Eye Consultants of Northern Virginia, PC Financial Policy
We are committed to providing you with the highest level of service and quality care. If you have medical insurance, we will strive to help you receive your maximum allowable benefits. Ultimately, however, any and all financial liability rests with the patient.
Our office participates with most major medical insurance plans:
- We will submit a MEDICAL and/or SURGICAL claim to your health insurance.
- We do not bill health insurances for routine exams
- We do NOT participate with ANY vision plans.
- You may submit a claim to your insurance to try and seek reimbursement for routine services. If you do not have a medical complaint you may be financially responsible for all charges at the time of service. Our charges for examinations are available upon request.
- If you have a managed care plan that requires a referral to see a specialist, you must obtain a referral prior to your visit to our office in order for your visit to be covered under your medical insurance.
- If you do not have a valid referral and wish to be seen, you will be asked to pay for the visit prior to your examination. It is the patient’s/parent’s/guardian’s responsibility to:
- Be familiar with the benefits of your plan, including co-pays, co-insurance and deductibles.
- Bring all of your current insurance cards to all visits.
- Provide our office with current information including address, phone numbers and employer
- In accordance with your insurance contract, you must be prepared to pay your co-pay at each visit.
- If you do not make your co-payment at the time of the visit, you will be charged an additional $10 billing fee.
- We accept cash, checks and all major credit cards for services. Additional Terms:
- Any check payments that do not clear the bank will be subject to a $35.00 returned check fee.
- There is a charge for completing various forms, including your DMV form. Pre-payment is required for completing the forms, or for extra written communication by the doctor. The charge is determined by the complexity of the form, letter, or communication.
- For all services rendered to children, we will look to the adult accompanying the patient and/or the parent or guardian with whom the child resides for payment. In cases of separation or divorce, when presenting insurance cards for a dependent enrolled under a subscriber other than you, please be prepared to supply their name, address, phone number, date of birth and social security number. We request that you inform the subscriber that their insurance has been used.
• We have a $50.00 no show fee if you fail to show for any scheduled appointments or cancel the same day as your appointment. Any patient who cancels a scheduled, elective surgery without giving more than five (5) business days notice prior to surgery, or does not show up for surgery, will be charged a cancellation fee of $250.00. Legitimate emergencies will be taken into consideration.
Insurance Authorization and Assignment of Benefits
I certify that the information that I have reported with regards to my insurance coverage is correct. I also authorize the release of any medical information necessary to process this claim. I also authorize payment of medical benefits to Eye Consultants of Northern Virginia, PC for medical and surgical services provided to me. I fully understand that payment for services is not contingent upon recovery and this does not relieve me of my primary obligation to pay.
In Medicare cases, Eye Consultants of Northern Virginia, PC, agrees to accept the charge determination of Medicare as the full charge, and the patient is responsible only for deductible, coinsurance and non-covered services. Coinsurance and the deductibles are based upon the charge determination of Medicare.