I hereby authorize any insurance company to pay the proceeds of any benefits due me directly to Retina and Vitreous of Texas, PLLC. A copy of this authorization can be considered an original for insurance purposes.
Minor patients must be accompanied by a parent, authorized adult family member, or legal guardian to all appointments. In addition, the financial responsibility for a minor patient is the responsibility of the accompanying adult unless prior arrangements have been made with this office.
I agree to and understand that my eye(s) must be dilated for the doctor to perform a thorough examination. I agree to and understand that my eye may need to be patched as part of the treatment of my condition. I understand that if my pupils are dilated or my eye is patched after the exam, I may not be able to safely operate a motor vehicle and that the staff and doctors of Retina and Vitreous of Texas, PLLC suggest that I evaluate my need for alternative transportation, and the decision is solely mine, and Retina and Vitreous of Texas, PLLC is in no way responsible for that decision.
A more detailed version of this financial policy is available here. A summary of your financial responsibility is below.
As a courtesy to you, our patient, Retina and Vitreous of Texas, PLLC will bill your insurance directly for services provided. Whatever amounts your insurance classifies as patient responsibility will be billed to you. For scheduled procedures and treatments, payment for services is due in full at the time of service. We will make every effort to create an accurate estimate of your financial responsibility prior to providing these services. If you have questions about your estimated financial responsibility, please call our billing department for assistance.
Payment in full for an account balance is due prior to your next visit. Our billing staff is available to assist with questions regarding your balance. If your account is past due, we will take all necessary steps to collect on the debt owed, including possible referral to a collection agency which may affect your credit record.
SELF PAY POLICY: We understand that you might not have insurance for your visit. We require a $250 deposit at the time of service. This will be applied toward the actual charges for your visit. If the charges for your visit exceed $250, the remaining balance will be billed to you. In the event the visit charges total less than $250, the difference will be refunded to you within 10 business days.
For your convenience, we accept cash, check, all major credit cards, and offer a secure online payment portal. Postdated checks are not accepted. A $25.00 return check fee will be assessed if your check is returned by your bank.
If you have any questions or complaints, please contact: Retina and Vitreous of Texas, PLLC, Privacy Officer, 2727 Gramercy St., Suite 200, Houston, TX 77025. Phone number: (713) 799-9975.
My signature below acknowledges I have received this Notice of Privacy Practices.
PLEASE SEND THE REQUESTED INFORMATION TO:
RETINA AND VITREOUS OF TEXAS, PLLC
ATTN: MEDICAL RECORDS
2727 GRAMERCY ST., SUITE 200
HOUSTON, TX 77025
PHONE: (713) 799 – 9975
FAX: (713) 799-1095
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