Forms

Financial Authorization Policy

Patients, or the legal guardians of patients under the age of 18, are financially responsible for the full payment of any and all services provided. Valid credit or debit cards are required at every appointment. Copays and any outstanding balances will be collected prior to all appointments.

ReFocus will keep each patient’s Credit Card Authorization Information on file. Should there be a patient balance post-insurance adjudication, the patient’s card will be charged for the outstanding balance.

Medical vs. Vision Benefits Notification

Medical Eye Exam Related to an eye complaint or pre-existing condition: Previous medical diagnosis, including but not limited to: cataracts, glaucoma, diabetes, thyroid eye disease, Plaquenil toxicity, etc. Any eye-related complaints, including but not limited to: eye discomfort, redness, tearing, etc.

Routine Eye Exam Eye exam done every year or every other year No pre-existing condition(s) General eye health check No diagnostic testing would be done with this type of visit No eye complaints of any nature

I acknowledge that I have read the above and fully understand the difference in nature of the exams. I understand that asking my physician to withhold a diagnosis would be committing insurance fraud. I also understand that, ultimately, it is the doctor’s decision how my claim will be billed, based on the findings of my exam and not based on my insurance coverage.

OUR MARYLAND OFFICES DO NOT PARTICIPATE WITH ANY VISION PLANS.

Our RI, PA, NJ, and SOME of our CT clinics do accept vision plans.

In locations that do not accept your vision plan, or, if you do not have vision coverage, routine coverage must be through your medical insurance policy.

Refraction Fee Disclosure

The refraction is the part of the exam in which ReFocus Eye Health checks to see if you need a new eyeglass prescription. Medicare and some other medical insurance companies do not pay for this service. Should a refraction be needed at this visit or at a future visit, in discussion with your doctor, an additional fee may be charged for this service. Charges for additional screening procedures may also apply. Before the exam, we will inform you of any additional charges related to a refraction and other procedures that you elect to have performed.

Insurance Payment Disclosure

***In locations that do not accept your vision plan, or if you do not have vision coverage, routine coverage must be through your medical insurance policy.***

1. I authorize ReFocus Eye Health to receive all insurance payments from my current medical
2. insurance plan.
3. I agree to pay applicable co-payments, deductibles, and non-covered fees at the time of service,
4. or upon first notification.
5. If my plan requires a prior approval or referral, I accept responsibility for all payments for non-
6. approved and/ or non-referred charges.
7. I agree to release all information necessary for my current insurance plan to process my claims.
8. I agree to pay in full at the time of service if I do not have insurance or choose not to have my insurance filed by your office.

Missed Appointment / Cancellation Policy

Our goal is to provide excellent care to each patient in a timely manner. In order for us to do this, we ask that you inform us if you are unable to attend your scheduled appointment. Your notification allows us to proactively fill that available appointment by serving another patient in need of our care.

If you need to cancel or reschedule your appointment, please call at least 24 hours before your scheduled appointment. You may incur a $50.00* cancellation fee if you cancel/ reschedule less than 24 hours before your scheduled appointment (late cancellation) AND/OR fail to arrive at the designated date and/or time of your appointment (missed appointment). Cancellation fees are billed directly to you (the patient), not your insurance, and are due prior to your next scheduled visit.

*Fees are subject to change. Bounced checks are subject to a service fee.*

With your help, we can continue to provide quality care and an exceptional experience to all of our patients in need of an appointment. Thank you!

Credit Card Authorization

As a convenience to our patients, ReFocus retains credit card information in a secure and compliant manner to assist with future payments. Once your insurance has been processed, a statement will be sent to you, detailing any balance. If payment is due and not received within 15 days of the statement dates, we will conveniently charge the credit card for your outstanding balance. ReFocus will keep each patient’s Credit Card Authorization Information on file.