<p> PEDIATRIC EYE CARE & SURGERY Sarah J. Whang, M.D. FINANCIAL POLICY</p><p>Child’s Name:______Child’s DOB:______</p><p>We continually strive to control healthcare costs and maintain a high level of professional care. One of the costliest aspects of doing business is carrying past due balances and sending out billing statements. In order to eliminate the expense of sending out billing notices, all fees for certain services are due at the time of the visit.</p><p>The following items are to be paid for at the time of your visit: Routine eye examinations Co-payments Deductibles Co-insurance amounts Refractions: This is a non-covered service by most medical insurance companies. If your insurance company pays the refraction fee, we will refund this amount to you in a timely manner. A refraction is needed to determine if your child needs glasses.</p><p>Your medical insurance will reimburse only those services that are covered by your policy. It is your responsibility to pay any fees to this office for services regardless of your benefit limitations. We do not bill your vision insurance.</p><p>The parent bringing the child to the office is responsible for the full amount of any fees due. Partial payments will not be accepted.</p><p>There will be a charge (a rescheduling fee) of $40 for missed appointments or for cancelling or rescheduling appointments with less than 24 hours notice.</p><p>A fee of $20.00 will be added to your account for a returned check.</p><p>In case of default, your account will be turned over to a collection agency, and 10% interest per year will be added for this process.</p><p>I understand that if the health insurance information provided by myself is not true or if I am not eligible under the terms of the Medical Subscriber Agreement, I am responsible for any and all charges for services rendered. </p><p>I agree to pay in full for all services rendered within 30 days of receiving a bill from this office.</p><p>RELEASE OF INFORMATION/ASSIGNMENT OF BENEFITS: I hereby authorize the release of any medical information necessary to process insurance claims and authorize payment of benefits to Pediatric Eye Care & Surgery.</p><p>I certify that I have read and fully understand and accept the above financial policy.</p><p>Signature of Responsible Party: ______</p><p>Please print Name of Responsible Party: ______</p><p>Relationship to Patient: ______</p><p>Date Completed: ______</p>