Effective: September 19, 2018
NOTICE OF PATIENT FINANCIAL RESPONSIBILITY
Insurance
Our office participates with many vision insurance companies. Should your insurance coverage be with one of these companies, we will bill your insurance accordingly. You are responsible for any co-payments, coinsurance, deductibles, and non-covered services that have not been covered by your insurance. Payments are expected at the time services are rendered.
I authorize treatment by Dr. Tam Ha. I also authorize the release of any information requested by insurance companies or liable third parties and I assign any insurance benefits to Dr. Tam Ha. If the correct insurance information is not given or the proper referral is not obtained, the patient will be responsible for the bill. If you are uncertain whether or not Dr. Tam Ha or any of our services are covered by your insurance plan, please call your insurance company prior to seeing the doctor.
Self Pay
If you are a self pay patient, paying out of pocket for your services, you acknowledge that you are fully responsible for all financial services and transactions. Payment is due in full at the time services are rendered.
Insurance Billing Policies
- I understand that if the office of Dr. Tam Ha, O.D. is not participating provider with my vision insurance, I am fully responsible for services rendered. As a patient, I understand that it is my responsibility to be aware of my insurance policies prior to my routine exam or medical visit, and to inform the office of my insurance in which to file. All insurance inquiries should be determined prior to the visit to prevent any delays in quality of service.
- In the event of default, declines, or rejection of claims by me or my insurance carrier, I further agree that I am responsible for unpaid balance of such charges. If such balance is not paid within 30 days after billing, and the account is referred to an attorney for collection, I acknowledge I will be responsible for acquired attorney fees of the unpaid balance plus all costs of collection.
- The staff of Dr. Tam Ha, O.D. will assist as possible in your insurance claims as a courtesy. Your eventual reimbursement or coverage will be determined by your insurance carrier. Any deductibles or co-payments are due at the time of your service or immediately upon notification of this office.
- Most additional testing within the office is NOT covered by the insurance. You are responsible for all additional fees that are not covered by your insurance.
Products Policy
- I understand that all contact lens, frames and lens orders are NON-REFUNDABLE once order has been placed. I acknowledge that I am fully responsible for all costs of my orders. All orders must be picked up within 60 days. If the order(s) are not picked up within 60 days, and there is no communication with the staff, I acknowledge the right to have my order returned.
ALL FEES ARE NON-REFUNDABLE AND MUST BE RENDERED AT TIME OF SERVICE!
I have read and understand the financial policy of this office. I guarantee payment of all charges incurred for the account of the below patient. By signing in the appropriate space on the forms given to you, you are agreeing that you understand and accept all financial responsibilities.
Policy Contact Officer: Cindy Ha