FINANCIAL POLICY

INSURANCE PLANS:
The physicians at Naperville Eye participate with most major insurance and managed care plans. Due to being a specialist practice, Naperville Eye does not participate with any vision plans. Please contact us at 630-357- 5280 to find out if we accept your insurance plan. Please understand our participation with carriers and their specific networks are subject to change which may or may not increase your financial responsibility.
This authorization remains valid and effective from the date of signing until revoked in writing. You represent that you presently maintain insurance which will reimburse Naperville Eye for the medical care provided. Therefore, you hereby assign, transfer and assign to Naperville Eye, all of your right, title and interest in medical reimbursement benefits under your insurance coverages and/or policies.
The patient’s/parent’s/guardian’s responsibility: 

• Familiar with the benefits of your insurance plan, including copayments, coinsurance and deductibles and be prepared to pay those financial balances at the conclusion of your visit. 

• Bring all your current insurance cards to all visits. 

• You understand Naperville Eye’s provider network status in your insurance plan.

• Notify us of any changes in your insurance status or insurance company preferably prior to your visit.

• Should there be a delay in your eligibility or there is notification of any change in your insurance information, you will be financially responsible at the time of the visit for full payment. Naperville Eye will refund any overpayment to you upon the reconciliation of your account.

HMO/POS/Referral Care:
You must obtain an authorization from your primary care physician prior to your appointment. You will be responsible for any charges above and beyond whatever treatment is listed on the authorization. It is your responsibility to know what services have been authorized and whether the authorization is valid for the date of service. If you choose to be seen without an authorization, you will be responsible for payment at the time of service for those services.

WORKER’S COMPENSATION:
All required documents to bill your Worker’s Compensation insurance carrier is required at time of service. Otherwise, payment is due at the time of service. If payment is not received from your Worker’s Compensation insurance carrier within ninety (90) days, then you are financially responsible for the balance.

COPAYMENTS, DEDUCTIBLES & COINSURANCES:
All copayments, deductibles and coinsurance must be paid at each and every visit. UNINSURED PATIENTS: Full payment is due at time of service. A two-hundred-dollar ($200.00) deposit is due prior to your appointment. This deposit will be applied to your charges. You will be responsible for any balance over the deposit at the time of discharge. If you paid more than the balance on your account, a refund will be processed within 10 business days from the date of service and mailed to the home address on file.

PAYMENTS:
We accept Visa, Mastercard, and Discover in addition to cash, or check. You will be financially responsible for all applicable bank service fees for any returned checks.

MEDICARE:
The physicians at Naperville Eye participate in Medicare and therefore we accept assignment of services. Medicare pays eighty percent (80%) of what it approves after the annual deductible, and you or your secondary insurance are responsible for twenty percent (20%).

MEDICARE ADVANTAGE PLANS:
You understand Medicare Advantage plans are not Medicare. You must abide by the policies and procedures of the Medicare Advantage. Failure to adhere to those policies and procedures may be subject to greater out-of-pocket financial expense.

ACCOUNT STATEMENTS:
You will receive a statement in the mail once your insurance has responded. Your prompt payment in full for any outstanding balance helps us from transferring billing costs. Any past due accounts may be referred to a collection agency after sixty (60) days of billing start date.

CONSENT FOR MINORS:
A parent/guardian who brings a minor child to the office shall be responsible for giving consent of treatment, authorizing payment for services, and payment for all fees incurred and owed at the time of service.

OUTSTANDING FINANCIAL BALANCE:
All outstanding financial balances must be paid prior to being treated. We will do our best to inform you of any outstanding balance at the time of making your appointment.

BENEFIT ASSIGNMENT:
The assignment of benefits of any insurance policy and/or healthcare reimbursement plan shall not be deemed a waiver of Naperville Eye’s right to require payment directly from undersigned, the patient or the guardian.

COLLECTION COSTS:
Should you fail to reimburse Naperville Eye for services rendered and your balance remains unpaid, this balance will be transitioned to a third-party collection agency for pursual of payment. The undersigned agrees to pay all costs of collections, including and not limited to reasonable legal and third-party fees. If it is necessary to use a collection agency to seek payment for my account, I will be responsible for all fees including collection agency fee (33 1/3%), attorney fees, any court costs and a $25.00 rebilling fee.

EMT/911 SERVICES:
If EMT/911 services are required in order to assist you during your encounter, you agree to accept full responsibility for the cost of this assistance to you.

DRIVER’S FIELD EXAM:
A Driver’s Field Exam is a visual field exam you elect to have done for the provider to complete paperwork provided by the Department of Motor Vehicles in order for you to obtain or renew your driver’s license. Regardless of your current medical condition, a Driver’s Field Exam is not medically necessary if the exam is not being conducted as a required or recommended component of your office visit. You will be financially responsible for a charge of twenty-five dollars ($25.00). Please note: This acknowledgement is ONLY valid when you have a Driver’s Field Exam done.

REFRACTIONS:
A refraction helps to evaluate the health and function of the eyes AND to determine your eye glass prescription. Your doctor may need to perform a refraction to evaluate your eye condition or measurements. The refraction is NOT covered by most insurances and Medicare. You will be financially responsible for a charge of forty dollars ($40.00).

MISSED APPOINTMENTS:
Naperville Eye requires at least a 24-hour notice to cancel an appointment. You may be charged a Late Cancellation/No Show fee of fifty dollars ($50.00).

MEDICAL RECORDS:
Each patient has a complete record of all medical care received at our office. Because your record is confidential, we will not release your records without your written consent, unless required so by law. There is a twenty-five dollar ($25.00) copying fee if you would like to pick up a copy of your records. If you provide a brand-new USB flash drive, we can upload them at no cost. We will continue to fax your records to your new physician as a courtesy.