When you make an appointment with our office, you should prepare to have your eyes dilated. You should also prepare to be in the office for at least 3 hours.
In that time, we will perform all necessary testing and prescribe you glasses and or contact lenses if necessary or requested. We accept Medicare and most insurance. Your co-pay, co-insurance, $75 refraction fee along with a nonrefundable contact lens evaluation fee (if contact lenses are address) is due at the time of service.
Payment Due: I understand that payment is due when service is rendered.
Co-pay, Co-insurance and Deductibles: It is my responsibility to know what my co-pay, co-insurance and deductibles are, and my obligation to pay this at the time of service.
Insurance Coverage: I acknowledge that the insurance cards I have presented are current and accurate.
Non-covered Services: I understand that some services may be considered non-covered services by my insurance plan. I understand that it is my responsibility to know what my insurance does or does not cover and I understand that I am financially responsible for paying all non-covered services.
Denied Charges: I understand that some charges may be denied by my insurance carrier as investigational, experimental or not medically necessary and will not be paid by my insurance carrier. I understand that depending upon my exam findings or diagnosis my physician may feel these services are needed whether my insurance carriers deems them payable or not and that I am obligated to pay for these services in full.
Medical Eye Examination Coverage: If you have an eye condition such as but not limited to: cataracts; macular degeneration; glaucoma; dry eyes; cornea problems, this examination will be billed to your medical insurance. Please note that the refraction (CPT 92015 – a test done to prescribe glasses and/or contact lens) fee is not always covered by you medical insurance and will be the patients responsibility.
Patient Responsibilities: Many medical insurance companies do not pay for a routine eye examination. We cannot and will not bill an eye examination to a patient’s medical insurance and vision insurance companies for the same date of service. It is your responsibility to check with your insurance carrier for proper coverage and to let us know before your eye examination. Please understand that each patient’s insurance coverage varies. The Kirby Eye Center staff verifies each patient’s insurance to the best of their ability and cannot be held responsible for knowing every patients’ coverage.
Refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of an eye examination and necessary in order to write a prescription for glasses or contact lens. Medicare and most medical insurance do not cover the $75 fee for refractions. I understand that I am responsible for this $75 fee and it is payable at the time of service. Types of payment accepted: Visa, MC, AMEX, Discover, Apple/Samsung/Google Pay. We can, at your request, file your refraction charge with your insurance plan. If your insurance policy pays this fee. We will then refund your payment or you may choose to leave a credit for your next visit. You can also make a payment through the Patient Portal here
Is this a Routine (Refractive) or Medical eye examination?
Routine Vision (Refractive) Coverage: Your “vision” insurance is intended to provide you with a baseline eye evaluation and update your glasses prescription only. If the doctor discovers a medical eye problem during a routine exam, the doctor will inform you that your visit is now a medical exam and will be billed to your medical insurance. You can choose to finish the routine examination and return at a later date for the medical exam.
Participating Insurance Plans: If the practice is not a participating provider in my insurance plan, I will be responsible for filing my own claims and I will be responsible for paying in full at the time of service.
Returned Checks & Past Due Accounts; Returned checks will be subject to collection charges, penalties and interest. The practice does not accept post dated checks.
Vision Plans: The practice excepts VSP, Eyemed and Superior Vision. We cannot and will not bill an eye examination to a patient’s medical and vision insurance companies for the same date of service. It is your responsibility to check with your insurance carrier for proper coverage and to let us know before your eye examination. Please understand that each patient’s insurance coverage varies. The Kirby Eye Center staff verifies each patient’s insurance to the best of their ability and cannot be held responsible for knowing every patients’ coverage. Please contact your carrier to verify your benefits and to see if the provider/office is in network for both your medical and vision plan.
No Show Appointments: all appointments that are not cancelled within 24 hours of appointment time are subject to a $30.00 no show fee. This $30.00 fee must be paid before we can reschedule your appointment.
Surgery Charges: The practice will give you estimated physicians fee amount for surgery charges, please keep in mind that this is just an estimate and is not a guarantee of payment by your insurance company. Please be aware that when surgery is performed, you may incur addition charges (in addition to the surgeon’s fees) from the surgery facility, anesthesiologist, laboratory or radiologist. These facilities are completely separate facilities that have their own billing and billing procedures.
Authorizations: Some insurance plan require you receive a prior authorization for services by a specialist, please review your policy to see if there is such a requirement and obtain this authorization prior to your visit with our clinic.
If you would like a printed copy of the financial policy please inform the receptionist.