BUSINESS OFFICE • POLICY 13 - Home - University of ...



university of houston

COLLEGE OF OPTOMETRY

University eye institute

CLINIC BUSINESS OFFICE • Policy 8.0

February 15, 2008

Financial Policy

It is the policy of the University Eye Institute to provide a copy of the UEI financial policy to every patient when requested.

Procedures

1. The financial policy includes information about the University Eye Institute’s policy as it relates to the following:

a. Insurance companies - participation and billing;

b. Time-of-service payment;

c. Patient’s responsibility;

d. Collections; and

e. Contact information for the business office.

2. The financial policy is available to patients when they register at the front desk.

University Eye Institute Federal Tax ID: 74-6001399

505 J. Davis Armistead Building

Houston, Tx 77204-2020

(713) 743-2020

FINANCIAL POLICY

Welcome and thank you for choosing the University Eye Institute for your eye and vision care.

We are committed to providing you with quality eye care. Our fees have been determined through careful consideration, and we believe these fees are reasonable. We will be pleased to discuss with you any questions you may have concerning your bill.

Regarding Insurance and Vision Plans

Indemnity and Private Insurance Policies: The University Eye Institute will file claims directly with your insurance carrier for services where covered benefits have been verified. Insurance verification does not guarantee your insurance will pay for services. Payment of co-pays, co-insurance, deductibles, or non-covered services, when applicable, is required at the time of service.

Contracted Managed Care Plans (HMO, PPO, POS, EPO, etc.): Each time you make an appointment with The University Eye Institute, it is your responsibility to ensure that the University Eye Institute is currently under contract with your plan and that you have obtained the necessary referrals when needed. Verification of your plan benefits / coverage is required. Often this verification requires us to share the reason for your visit with the managed care plan. Payment of co-insurance, co-pays, deductibles or non-covered services, when applicable, is required at the time of service.

Vision Plans and other Organizational benefits: Each time you make an appointment with the University Eye Institute, it is your responsibility to ensure that the University Eye Institute is currently under contract with your plan and that you have obtained the necessary referrals when needed. Verification of your plan benefits / coverage is required. Often this verification requires us to share the reason for your visit with the vision plan or organization providing your benefits. Payment of co-insurance, co-pays, deductibles or non-covered services, when applicable, is required at the time of service.

Medicare: The University Eye Institute accepts assignment of Medicare benefits; however, you may be asked to sign a waiver to acknowledge your understanding of your responsibility to pay for services not covered by Medicare.

Medicaid: The University Eye Institute participates in the Medicaid program for the State of Texas. It is your responsibility to ensure that the University Eye Institute is currently under contract with your assigned Medicaid Plan and that you have obtained the necessary referrals when needed.

Eye Care Assistance Program: The University Eye Institute Eye Care Assistance Program is available to assist financially challenged individuals in need of eye care. Your eligibility for the program depends on your income, other help you receive or could receive, and the number of household dependents. Applications for the assistance program are available in the University Eye Institute Business Office.

Method of Payment: For your convenience, The University Eye Institute will be happy to accept your personal check, cash, Visa, MasterCard, Discover, or American Express for payment of your eye care services. A $25.00 fee will be accessed to your account for all returned checks.

CareCredit: The University Eye Institute offers no interest or low interest financing plans with CareCredit. CareCredit offers flexible financing options. Credit decisions usually take a few minutes and there are no annual fees or prepayment penalties. Applications are available in the University Eye Institute Business Office.

Minors: The parent(s) or guardian(s) of a minor are responsible for providing current insurance and vision plan information for the minor and / or payment in full for services provided. Unaccompanied minors must have an authorization for medical treatment signed by the parent or guardian.

Refunds: Credit balances resulting from the overpayment on an account by the patient or responsible party will be used first to offset outstanding balances which are the patient’s liability, with excess being refunded to the appropriate responsible party. Refunds that are a result of credit card payments will be refunded to the appropriate credit card account. Refunds to insurance carriers will be refunded in accordance with guidelines provided by the insurance carrier.

To assist us in updating your University Eye Institute financial account, please provide current insurance information and authorize release of information, if necessary, for filing insurance and vision plans and precertification by signing the statements below.

I have read and understand the above terms and conditions and will verify so by my signature.

________________________________________________

Signature Date

Insurance Assignment and Authorization to Release Information

I request payment of authorized Medicare, Vision Plan, or other Insurance Company benefits be made on my behalf to the University Eye Institute for any services provided me by that party who accepts assignment. Regulations pertaining to Medicare Assignment of Benefits apply.

I authorize the holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare, Vision Plan, or Other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical and/or vision insurance benefits to the University Eye Institute who accepts assignment. I Understand it is mandatory to notify the University Eye Institute of any other party who maybe responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C 3801-3812 provides penalties for withholding this information).

Patient Name:_______________________________________ ________________________________________________

Signature Date

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