Eye Physicians of Orange County, P.C.
1. You will be expected to pay to today’s visit in full. If full payment is not received today, any balance that remains must be paid within 10 days to avoid a $5.00 billing surcharge. A surcharge will be added to your balance for each statement sent out.
2. If after 90 days your balance is not paid, your account may be sent to a collection agency. There will be a collection fee of 29% of the total amount being billed, which will be added to your balance to cover legal and collection fees.
3. I understand that Eye Physicians of Orange County, PC, reserves the right to charge $50.00 if you,( the patient) fails to keep or cancel appointment within 24 hours notice.
4. Refraction is the procedure during which the doctor or ophthalmic technician determines your eyeglass prescription. Medicare and nearly all-commercial insurance carriers DO NOT COVER THIS SERVICE. There will be a separate charge of $30.00 for this service. Payment is expected on the day of service.
5. Please be advised that if you do receive an eyeglass prescription today is based on a calculation, which is a subjective process. Eye Physicians of Orange County, PC will not be financially responsible for any adjustment that need to be made once your prescription has been filled, unless the prescription is filled in our Optical Shops located in Goshen or Monroe office.
6. I have been made aware of the HIPAA, HEALTH PORTABILITY AND ACCOUNTABILITY ACT OF 1996, which is displayed in patients lounge.
7. I have been notified by Eye Physicians of Orange County, P.C.that in case my insurance company/Medicare denies payment because they feel it is not medically necessary, I agree to be personally and fully responsible for payment.
Patient Signature________________________________ Date:_______________
I give the following individual permission to obtain information pertaining to my medical care: