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It explains how deductibles, co-insurance, co-payments, and non-covered charges are handled, including possible deposits and subsequent billing after claims process. The agreement covers insurance participation, ABN use for non-covered services, specific fees for refractions and contact lens fittings, returned check charges, and no-show rules. It also details medical record copy fees, forms completion costs, and patient authorization for disclosures, assignment of benefits, and consent to treatment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":21,"@type":70,"position":76},"https://docshare.wps.com/template/invoices/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-financial-agreement-acknowledgement-of-office-policies/359038/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-financial-agreement-acknowledgement-of-office-policies/359038.png","ImageObject",442,249,{"name":88,"@type":89},"Taylor Morgan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-15","2026-09-23",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"When is payment expected for services?","Question",{"text":109,"@type":110},"Payment is expected at the time of the visit. If a deductible is not met, the patient may be required to pay a $125.00 deposit at check-in, and unmet deductibles and other non-covered amounts must be addressed per policy.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the clinic handle insurance coverage and referrals?",{"text":114,"@type":110},"The clinic files claims for participating insurance plans, but insurance is still a contract between the patient and the insurer, so the patient remains responsible for payment in full. If a managed care plan requires a referral to see a specialist and no valid referral is provided, the patient may be asked to pay for the visit before services.",{"name":116,"@type":107,"acceptedAnswer":117},"What fees apply for non-covered services and for no-shows?",{"text":118,"@type":110},"For non-covered services, an ABN may be provided, and payment in full is due at the time of service; refractions are charged $49.00 when performed, and contact lens fitting has a separate charge based on benefits. No-shows require a $50.00 fee, which must be paid before the next visit, and two or more no-shows in a 12-month period may result in dismissal from the practice.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},359038,1791387385,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":20,"category_name":21,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1099523885336,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIES  \nOphthalmology Associates believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have a  \nfull understanding of our policies.  \n1. PAYMENT is expected at the time of your visit. If you have a deductible that is not met, you may be required to pay a $125.00 deposit at check in. We accept cash, check, Visa, Mastercard, Discover, and Care Credit on select procedures. Payment will include any unmet deductible, co-insurance, co-payment amount, charges not covered by your insurance company. If you do not carry insurance, or if your coverage is currently under a preexisting condition clause, payment in full is expected at the time of your visit. All non-filed services are expected to be paid at the time of service. For patients with insurance, payments collected are an estimate based on the benefits provided to us from your insurance company. Once claims have processed, if there is any remaining balance, you will receive a bill in the mail.  \n2. INSURANCE: We are participating providers with most insurance plans. We will file all of the claims for these plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. As a courtesy to our patients, we will verify your insurance coverage, however, our verification is not a guarantee of benefits payable by your insurance. If you have a managed care plan that requires a referral to see a specialist, you must obtain a referral in order foryour visit in our office to be covered under your medical insurance. If you do not have the valid referral and still wish to be seen, you will be asked to pay for the visit prior to your services. In order to bill your insurance and to meet filing guidelines we do ask for a copy of your insurance card and a photo ID.  \nIf our providers are not listed in your plan’s network, you may be responsible for partial or full payment.  \n3. POLICY ON NON-COVERED SERVICES: This office offers access to many innovative services and procedures some of them are deemed as “not covered” by insurance. In some cases, you will be given an ABN (Advanced Beneficiary Notice) for these types of services/procedures before they are provided/performed. You will be responsible for payment in full at the time of service.  \na. Refractions-A refractive examination is not a covered service by most insurance companies, including Medicare. If you receive a refraction, you will be charged $49.00 which is payable at the time of the visit.  \nb. Contact Lens Fitting – In order to receive a contact lens prescription, a contact lens fitting must be performed. There will be a separate charge for the fitting which may or may not be covered by insurance. Based on your benefits, you will be required to pay for your fitting in full before receiving your contact lens prescription.  \n4. RETURNED CHECKS will incur a $50.00 service charge.  \n5. NO SHOW POLICY: We understand that situations arise in which you must cancel your appointment. We  \nrequest that if you must cancel your appointment, please provide a 48-hour notice. Patients who do not show up nor provide more than a 48-hour notice are considered a NO SHOW and will be charged a No Show Fee of $50.00. This fee is charged to the patient, not the insurance company, and must be paid before their next visit.  \nPatients who No-Show two (2) or more times in a 12-month period, may be dismissed from the practice.  \n6. FORMS FEES:  \na. Medical record copies – Medical record copy requests made by the patient for their personal use, for an insurance company, an attorney, etc., will incur a copying fee, as directed by the state statute and are as follows, following the completion of a release of medical records form:  \n$25.00 for the first 20 pages","cbCaiv0fUPJlkzxv","https://ap.wps.com/l/cbCaiv0fUPJlkzxv","pdf",163755,"English","# Payment\n# Insurance\n## Policy on Non-Covered Services\n# Returned Checks\n# No Show Policy\n# Forms Fees\n## Medical record copies\n## Forms completion\n# Responsibility for Payment\n# Authorization & Assignment of Insurance Benefits\n# Consent and Disclosures\n# Release of Information\n# Self Pay Patients Who Are Insured","[{\"question\":\"When is payment expected for services?\",\"answer\":\"Payment is expected at the time of the visit. If a deductible is not met, the patient may be required to pay a $125.00 deposit at check-in, and unmet deductibles and other non-covered amounts must be addressed per policy.\"},{\"question\":\"How does the clinic handle insurance coverage and referrals?\",\"answer\":\"The clinic files claims for participating insurance plans, but insurance is still a contract between the patient and the insurer, so the patient remains responsible for payment in full. If a managed care plan requires a referral to see a specialist and no valid referral is provided, the patient may be asked to pay for the visit before services.\"},{\"question\":\"What fees apply for non-covered services and for no-shows?\",\"answer\":\"For non-covered services, an ABN may be provided, and payment in full is due at the time of service; refractions are charged $49.00 when performed, and contact lens fitting has a separate charge based on benefits. No-shows require a $50.00 fee, which must be paid before the next visit, and two or more no-shows in a 12-month period may result in dismissal from the practice.\"}]","PATIENT FINANCIAL AGREEMENT - & ACKNOWLEDGEMENT OF OFFICE POLICIES | PDF",1790135931]