Statement of Financial Policy

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TERMS: Payment for professional services is due at time of service. Orders for optical materials must be accompanied by a 50% deposit, with balance due upon delivery. Orders not picked-up within 30 days of original order date will be billed for balance due. Orders not picked-up within 60 days of original order date are subject to cancellation, with forfeiture of deposit made. Spectacle lens orders, once lens fabrication has begun, cannot be cancelled, and patient is responsible for any optical laboratory charges we incur. Cancelled orders and orders not picked up within 60 of order date may be subject to a 15% restocking fee.

If you have insurance, payment for private-pay portion is due at time services are rendered. This includes your co-pay, deductibles on covered items, and full amount of non-covered items. After we remit your insurance, any remaining balance is due in full 14 days after we bill you for the outstanding balance.

INSURANCE: Insurance is a contract between the patient and the insurance company. We are NOT a party to that contract. The patient is responsible for being knowledgeable of their insurance plans, prior to the time services are rendered. If you do not present your insurance information BEFORE your visit, once services are rendered, the patient is personally responsible for all charges incurred, because some insurances require pre-certification or prior authorization from you primary care physician, some require your lens/materials be ordered from a particular supplier, or we may not be an in-network provider of the plan. We will assist you in determining your benefits, and processing your insurance claims.

PAYMENT TYPE. We accept cash, personal checks, and most major credit cards. We do not accept third-party checks, payroll checks, checks for greater than the amount of purchase, or traveler's checks. Bartering is not an accepted form of payment.

CHECK ACCEPTANCE POLICY: Checks from new patients require Photo ID (i.e., driver's license), proof of your Name, Current Address, Phone Number, and Social Security Number.

RETURNED CHECKS: If your check is dishonored for any reason, we reserve the right to automatically debit your account electronically for the face value of the check, plus a $30.00 processing fee (from NSF Resources, INC.), plus applicable sales tax, without further notice. In addition, you may be subject to up to a $30.00 fee from Suburban Vision Care, Inc. for administrative costs. If your account is closed, or does not have a balance sufficient to cover your check, you may be subject to the following: monthly repeat billing charges, interest, or additional fees incurred as a result of collection efforts.

MINOR CHILDREN OF DIVORCED PARENTS: The parent who accompanies the child to our office is financially responsible for charges incurred in the examination, diagnosis, and treatment of minor children. We are not in the collection business. The divorce decree is a contract between the parents. We are NOT a party to that contract. If the decree states the other parent is financially responsible for medical bills, the parent accompanying the child to our office is responsible for payment of charges at the time services are rendered. You will be given an itemized statement of your charges and payments. You may submit this bill to your ex-spouse for re-imbursement of your incurred expense. No exceptions. Minor children must be accompanied by parent or legal guardian at time of visit.

Policies subject to change without notice. Above is a summary of our policies.

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Punctal Plugs for treatment of Dry Eye Syndrome

Punctal Plugs are an alternative to ocular lubricating drops for treatment of chronic dry eye. Safe, effective, and painless, call our office for more information on this innovative new treatment.

Also RESTASIS is available by prescription at our office.

www.Restasis.com

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