This information is provided so that our clients are fully informed of our policies. Please read and sign below
Fees: Our fees reflect the level of care that you receive and the training of the doctors. Estimated amounts of services may be given, but the final amount may be different depending upon the employer plan and other circumstances
Insurance: Your policy is a contract between you and your insurance company. As a courtesy, we bill your insurance carrier, but you are ultimately responsible for the entire bill. If your insurance company does not pay the practice within 90 days, we will expect payment from you. If we later receive a check from your insurer, we will refund your overpayments. Unpaid balances accrue interest at the rate of 1.5% monthly (18% APR) and are send to a Collection Agency after 120 days. If you insurance plan determines a service is not covered, you will be responsible for the full charge. Co-pays, deductibles, and co-insurance are required on the day of service. If the co-pay is not paid at the time of service, a $10 billing fee will be charged. Uncollected fees, either from the insurance, insufficient funds check, stop payment, credit card chargebacks, etc. remain the responsibility of the patient (parent or legal guardian, if a minor). When insurance benefits are verified, the information provided by the customer service representative is NOT A GUARANTEE OF PAYMENT
Materials: Contact lenses require half-down prior to ordering. Glasses require full payment prior to dispensing
Assignment of Benefits: (Applicable if we are filing with Vision or Medical Insurance for you.) At each visit, patients are questioned about any changes in their insurance coverage and insurance card is copied. This is crucial so that your visit is billed correctly. We require all patients to sign a copy of the patient registration form that assigns insurance benefits to be directly to Northwest Family Eye Care, PLLC. If your insurance company sends a payment directly to you, it is your responsibility to make payment to Northwest Family Eye Care, PLLC.
"I hereby authorize my insurance/medical benefits to be paid directly to Northwest Family Eye Care, PLLC. I further authorize release of any medical records or information necessary to process this claim." This assignment of benefits may be revoked by the patient at any time, with prior written notice.