The office of John A. Riley, OD will do everything in its power to help me bill my vision insurance plan for the services I receive at this office. I will provide their office with all necessary information to allow them to do this service for me. I will include the name, date of birth, address, phone number and e-mail address (if applicable), name of insurance plan, and the ID# of the primary insured person, as well as the patient so that the office may bill my insurance company. Any co-pays owed to the office will be paid on the day service is rendered. If the copay is not known by the time of the services, I will be sent a statement which will show the amount due and I will pay this amount within 30 days. Any remaining balance owed after 30 days will be subject to a $25 late fee which will be added to the following statement. Failure to pay these fees beyond 180 days will cause the office to send my outstanding balance to a collections agency and my credit may be adversely affected.
This office will not do any “back-billing” on my behalf. If I fail to inform the office of my vision insurance, or exclude any of the required information needed to bill my insurance, then I will pay for the services personally and attempt to bill my insurance plan myself. The office will give me the billing information, such as the procedure and diagnosis codes, in order to help facilitate this process. However, the office will not bill this information for me. Also, if I have previously paid out of pocket for services, and then determined that I have vision insurance coverage, the office will not refund monies and back-bill for the services already rendered. It is my responsibility to know how my vision insurance coverage works, and any information given by the office about my insurance information should be verified.
If no insurance is to be billed, then payment is due today for any services received today. If I fail to pay for services the day they are rendered, I will be sent a billing statement and will pay the amount owed within 30 days. If I do not pay the entire balance within 30 days, a late fee of $25 will be added to my next statement. Failure to pay these fees beyond 180 days will cause the office to send my outstanding balance to a collections agency and my credit may be adversely affected.
By signing below, or selecting “yes” on the acknowledgement of Billing/Payment Policies question on the patient portal, I acknowledge that I have read and agree to the statement above.