Financial Policies Required Agreement to Provisions
The following is a statement of our Financial Policy that we require you read, understand, and sign prior to any treatment.
Patient Information Form
All patients must complete our Patient Information form before seeing the doctor. We verify your insurance information at each visit, so please bring your insurance card(s) with you to every appointment. In order for us to bill your insurance company we need complete, current, and accurate information, including a copy of your card.
No Insurance
If you currently have no insurance, all services provided are to be paid in full at time of service.
Co-pays, Deductibles and Co-Insurance
All co-payments, deductibles, and co-insurance are due at the time of check-in. All Medicare patients will be required to pay their yearly deductible and the 20% coinsurance, based upon the current Medicare Fee Schedule, at the time of services unless proof of secondary policy is evident.
Methods of Payment
Payments may be made with cash, personal check, VISA, MasterCard, Discover or American Express.
Contracted Health Service Plans
It is your responsibility to determine if you belong to an insurance plan with which Glaucoma Consultants of Texas contracts. It is your obligation to pay the full charges of all services rendered by Glaucoma Consultants of Texas if you belong to an insurance plan that is not a contracted insurance or is out of network.
Covered Services
Glaucoma Consultants of Texas contracts with health care service plan (i.e., HMOs, PPOs) related only to items and services which are "covered" by the health care service plans. Accordingly, it is your full financial responsibility for all items or services which are determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient; and treatment or tests not authorized by the health care service plan. The patient or guarantor agrees to cooperate with Glaucoma Consultants of Texas to obtain necessary health care service plan authorizations.
Delinquent Accounts and Collections
In return for the services provided by Glaucoma Consultants of Texas, you are required to pay the account at the time service is rendered or make financial arrangements satisfactory to Glaucoma Consultants of Texas for payment. If an account is sent to an attorney for collection, it is your responsibility to pay collection expenses and reasonable attorney’s fees as established by the court. If your account is delinquent, it will be charged interest at the legal rate. Any benefits of any type, under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to Glaucoma Consultants of Texas. If co-payments and/or deductibles are designated by your insurance company or health plan, you agree to pay them to Glaucoma Consultants of Texas.
Balances Due After Insurance
If the Clinic is a participating provider with your PPO or other insurance plan, we file charges to your insurance carrier. After the insurance company responds and if there is a balance due from the patient, you will receive a statement showing the charges, any payments, and the balance due. Although we have filed the charges to your insurance company, please remember that you are responsible for the
account balance. Interest at the maximum allowed by law will be charged on all balances after 30
days.
No-Show Appointments
A "no show" fee will be assessed to your account if you reschedule/cancel your appointment without advance notice. There will be a $20 fee for Follow Up appointments and a $50 fee for Laser appointments without 48 hours notice. There will be a $50 fee for New Patient appointments and a $250 fee for Surgery appointments without 72 hours notice.
Failure to Meet Financial Obligations
All account balances are due in full within 14 days of the billing date. Failure to meet your financial obligations may result in a collection action for your account balance. This may include the account being turned over to a collection agency, reported to a credit bureau, a claim filed for a judgment in small claims court. Once the account is placed in the collection status, your future services at the Glaucoma Consultants of Texas will be suspended. The outstanding balance must be paid in full before you can be seen again in the clinic. Your account will then be on a cash, credit card, or money order basis only. All attorney fees, court costs, and other expenses that relate to collecting your account will be added to your outstanding balance.
All outstanding patient account balances must be paid in full before your next visit or your appointment will be rescheduled.
Overpayment and Refunds
If an over payment is made by you on the account, a refund will normally be issued if there are no other outstanding debts on your account or other account or other accounts containing the same guarantor or financial responsible party. It is your responsibility to inform us of any change in address, phone, employment or insurance.
Returned Checks
There will be a $25 charge for all returned checks. If the check is forwarded to the District Attorney’s office for non-payment collection, additional charges will be the patient’s responsibility. Your account status following a returned check will be on a cash, credit card or money order basis only.
Refusal to Pay
It is our obligation under many of the managed care contracts to report patients who repeatedly refuse to pay co-pays and deductibles at the time of service or who repeatedly "no-show" for appointments. Your healthcare benefits could be lost due to non compliance.
Divorce Issues
Glaucoma Consultants of Texas will not become involved with any divorce issues. The adult accompanying a minor and the parents (guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized for payment by Visa/MasterCard/Discover, American Express, cash or check at time of service. The guarantor will be responsible for any balance on the account. Unresolved accounts will result in the account being sent to collections, regardless of who is responsible for the balance due.
Third-Party Liability Insurance
Glaucoma Consultants of Texas does not bill third parties such as attorneys or automobile insurance for liability services. Glaucoma Consultants of Texas will provide any documentation to the patient to submit to a third party for reimbursement. Medical records requested by the third party are to be paid in advance of release.
The foregoing financial policies are provided for your convenience. As a patient of Glaucoma Consultants of Texas, you must agree to these terms by signing and submitting an official paper copy of our financial policy, available from our Forms for New Patients page.
If you have any suggestions or comments to improve our practice, your care, or our web site, please feel free to contact us.