UNIVERSITY OF HOUSTON



university of houston

COLLEGE OF OPTOMETRY

University eye institute

CLINIC BUSINESS OFFICE • Policy 5.0

February 15, 2008

FEE ADJUSTMENTS

Eye Care Assistant Program (ECAP)

The University Eye Institute is committed to provide optimal vision services whenever possible regardless of the ability to pay. Patients who cannot afford the fee for examination services or spectacles should be referred to the Clinic Business Office before an appointment is scheduled for information on our ECAP program.

Patients are screened for a fee adjustment on the basis of income and family dependents. The scale used is the Poverty Income Guidelines as set by the Department of Health and Human Services and is similar to the scale employed by the Harris County Hospital District.

Patients are asked to provide information on income and verification is required. Patients may speak to the designated staff in the Clinic Business Office prior to an appointment. The patient will be advised regarding the specific information requested for fee adjustments. Unless specifically noted, ECAP qualifies the patient for reduced fees for 6 months, after which the patient will need to requalify. Patients can be referred to the Clinic Business Office for a fee adjustment screening prior to their appointment. Designated employees in the Clinic Business Office have the authority to verify the patient’s income and complete the fee adjustment forms. If there are specific questions that need to be addressed you may request to speak to the UEI Clinic Business Office Administrator.

There are established prescription guidelines for lenses available through the ECAP program. For powers outside these limits, all efforts will be made to provide lenses at reduced cost. Should the patient choose to add extras, that cost will be paid by the patient.

Patients who are prescribed contact lenses because their vision cannot be corrected with a spectacle Rx and they cannot afford contact lenses, should be referred to the Service Director of the Cornea and Contact Lens Service before the lenses are fitted. Individual arrangements may be made for reduction of professional service fees. However, payment must be received for all materials at the usual and customary rate unless otherwise approved.

Educational Purposes

Service Directors may make individual arrangements with a patient who qualifies for a reduction in fees for educational purposes. Only the Executive Director of the UEI and/or Service Directors have the authority to approve the educational fee adjustments.

Other Resources

The following resources are available for patients who cannot afford payment for the spectacle Rx or contact lenses. For example:

1. New Eyes for the Needy: We receive a limited number of vouchers per month from this organization to pay for glasses and frames.

Details are available in the UEI Clinic Business office.

No Charge - No Payment Due

Every patient should have a Patient Fee Statement issued each time they enter the clinic. All patients seen without incurring additional charges should be managed in the same manner as paying patients when they exit the clinic. Patients should be escorted to the reception area by the student clinician and thanked for coming. The cashier should promptly review for accuracy then separate the Patient Fee Statement giving the patient the pink copy if requested, keeping the canary copy and returning the white copy to the Service. If an Rx is attached, the patient should receive their copy.

Gratis/Professional Courtesy

Professional courtesy may only be approved through the Executive Director of the UEI or Service Directors. This may be in the form of total or partial fee waiving. The University Eye Institute extends professional courtesy to its faculty, staff, students, and members of their immediate family, if third party payment is not available or does not apply.

Immediate family is defined as spouse, children, parents, and siblings. Professional courtesy will be extended for services only. In no instance will material costs be waived.

Research Subjects

Occasionally, research subjects will be compensated for participation in approved projects. Investigators must acquire and fill out proper fee waiver forms and present them to the appointment clerk or Service Coordinator when making the subject's appointment.

Sponsored Program Fees

Occasionally, organizations will sponsor screenings and/or vision examinations for specific patient groups. Fee arrangements will be made in advance and will not follow normal billing procedures.

EYE CARE PROGRAM

FOR

FULL TIME UNIVERSITY STUDENTS

This program is designed to offer the services of the UNIVERSITY EYE INSTITUTE to all full time University students at all campuses. Professional courtesy applies only to those individuals who do not have a third party source of payment, UEI is not a provider in their third party plan, or the services provided are not covered by insurance.

The plan is as follows:

Full time University students at all campuses (UH, Rice, TSU, HBU, A&M, etc.) with a current identification card are eligible for a forty (40) percent courtesy reduction on the complete eye exam. Students will also be eligible for the same fee reduction for the Cornea & Contact Lens and Medical Eye Services. This program does not apply to students enrolled in trade schools, technical schools, etc.

Full time University students at all campuses are eligible for a 10% reduction in the cost of spectacles and contact lenses for personal use.

The UNIVERSITY EYE INSTITUTE provides the following vision and eye care services:

A. FAMILY PRACTICE SERVICES - include:

- ADULT AND GERIATRIC VISION CARE

- CHILDRENS' VISION CARE

- ROUTINE EYE AND VISION CARE

B. SPECIALTY CARE SERVICES - include:

- COLOR VISION ASSESSMENT

- CONTACT LENS SERVICES

- DEVELOPMENT CLINIC

- ELECTRODIAGNOSTIC SERVICES

- EYE MOVEMENT STUDIES

- LOW VISION CLINIC

- OPHTHALMIC PHOTOGRAPHY

- MEDICAL EVALUATION / OPHTHALMOLOGY CLINIC

- PEDIATRIC SPECIALTY CLINIC

- PEDIATRIC OPHTHALMOLOGY CLINIC

- STRABISMUS / BINOCULAR VISION CLINIC

- SPECIAL PROCEDURES

Visual Field testing

Laser Interferometry

A and B Scan Ultrasonography

C. OPTICAL SERVICES - include:

- PRESCRIPTION SPECTACLES AND SUNGLASSES

- NON-PRESCRIPTION SUNGLASSES

- SPORTS DEVICES AND PROTECTIVE SPECTACLES

- OCCUPATIONAL LENSES (V.D.T., special multifocal lenses, etc.)

To make an appointment or obtain information about our Primary Care Services, call 713-743-2020.

For specific questions or to obtain information about our additional services, please call:

Adult & Geriatric Services 713-743-2020

Children's Vision 713-743-2005

Center for Sight Enhancement (Low Vision) 713-743-0799

Color Vision Assessment 713-743-2010

Contact Lenses 713-743-2015

Development Clinic 713-743-2005

Ocular Emergencies 713-743-2010

Optical Services 713-743-2030

Primary Vision Care 713-743-2020

Vision Therapy 713-743-2005

The UNIVERSITY EYE INSTITUTE is located at 4901 Calhoun Road, entrance number 2, 505 J. Davis Armistead Bldg. Hours of operation are 8:00 A.M. - 6:00 P.M., Monday - Wednesday - Friday; 8:00 A.M. - 8:00 P.M., Tuesday & Thursday.

EYE CARE PROGRAM

FOR THE

UNIVERSITY OF HOUSTON

BENEFITS ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS

This program is designed to offer the services of the UNIVERSITY EYE INSTITUTE to all benefits eligible employees of the University of Houston. The program applies to all benefits eligible employees as well as their dependents. Professional courtesy applies only to those individuals who do not have a third party source of payment, UEI is not a provider in their third party plan, or the services provided are not covered by insurance.

The plan is as follows:

Professional service fees for primary care, comprehensive examinations are reduced forty (40) percent from the usual and customary fee.

Specialty care services are provided at the usual and customary fee, but may be reimbursed through the University Health Insurance Program for certain conditions.

Benefits eligible employees and their dependents are eligible for a 10% reduction in the cost of spectacles and contact lenses for personal use.

The UNIVERSITY EYE INSTITUTE provides the following vision and eye care services:

A. FAMILY PRACTICE SERVICES - include:

- ADULT AND GERIATRIC VISION CARE

- CHILDRENS' VISION CARE

- ROUTINE EYE AND VISION CARE

B. SPECIALTY CARE SERVICES - include:

- COLOR VISION ASSESSMENT

- CONTACT LENS SERVICES

- DEVELOPMENT CLINIC

- ELECTRODIAGNOSTIC SERVICES

- EYE MOVEMENT STUDIES

- LOW VISION CLINIC

- OPHTHALMIC PHOTOGRAPHY

- MEDICAL EVALUATION / OPHTHALMOLOGY CLINIC

- PEDIATRIC SPECIALTY CLINIC

- PEDIATRIC OPHTHALMOLOGY CLINIC

- STRABISMUS / BINOCULAR VISION CLINIC

- SPECIAL PROCEDURES

Visual Field testing

Laser Interferometry

A and B Scan Ultrasonography

C. OPTICAL SERVICES - include:

- PRESCRIPTION SPECTACLES AND SUNGLASSES

- NON-PRESCRIPTION SUNGLASSES

- SPORTS DEVICES AND PROTECTIVE SPECTACLES

- OCCUPATIONAL LENSES (V.D.T., special multifocal lenses, etc.)

To make an appointment or obtain information about our Primary Care Services, call 713-743-2020.

For specific questions or to obtain information about our additional services, please call:

Adult & Geriatric Services 713-743-2020

Children's Vision 713-743-2005

Center for Sight Enhancement (Low Vision) 713-743-0799

Color Vision Assessment 713-743-2010

Contact Lenses 713-743-2015

Development Clinic 713-743-2005

Ocular Emergencies 713-743-2010

Optical Services 713-743-2030

Primary Vision Care 713-743-2020

Vision Therapy 713-743-2005

The UNIVERSITY EYE INSTITUTE is located at 4901 Calhoun Road, entrance number 2, 505 J. Davis Armistead Bldg. Hours of operation are 8:00 A.M. - 6:00 P.M., Monday - Wednesday - Friday; 8:00 A.M. - 8:00 P.M., Tuesday & Thursday.

PROFESSIONAL COURTESY FOR SERVICES AND MATERIALS

The following is the policy for fee reductions provided by the University Eye Institute. Professional courtesy applies only to those individuals who do not have a third party source of payment, UEI is not a provider in their third party plan, or the services provided are not covered by insurance.

(Revised: March 1, 2005)

EXAMINATIONS and PROFESSIONAL SERVICES:

1. A fund has been established to cover the insurance co-payments for UHCO students, benefits eligible employees, and retirees in and from the College of Optometry. Immediate family members (i.e., spouse, children, parents, siblings, step-children and step-parents) are also eligible for services by using the College co-pay program and their insurance. The fund will cover the co-pay and the third party carrier will be billed for the remainder of the fees.

2. Relatives of UHCO faculty, staff, and students who are not immediate family members, (i.e., in-laws, nieces, nephews, aunts, uncles, grandparents, and grandchildren), are eligible for a 50% courtesy reduction on fees for professional services.

3. Full time University and College students at all campuses (UH, TSU, Rice, HBU, A&M, HCC, etc. - not their immediate family) with a current identification card (proof of enrollment) are eligible for a 40% courtesy reduction on all professional services. This program does not apply to students enrolled in trade schools, technical schools, etc.

4. Benefits eligible faculty, staff, and other employees of the University of Houston and Texas Southern University and their immediate family members are eligible for a 40% courtesy reduction on fees for professional services. This same courtesy will be extended to retired University of Houston faculty and staff with proper identification, as well as their family members.

5. Health Profession Students with a current identification card (i.e., dental, medical, nursing, osteopathic, pharmacy, podiatry, chiropractic, etc.) are eligible for a 40% professional courtesy on all professional services. This same professional courtesy will be extended to practitioners in health related fields (i.e., D.D.S., M.D., R.N., etc.).

6. UHCO workstudy students are eligible for one comprehensive eye examination without charge after being employed for a minimum of 90 days. These exams are to be scheduled at "off peak" times to fill needed appointments. Examinations are to be arranged on an individual basis via the Service Directors.

7. The College of Optometry has a minimum fee of $10.00 for professional services. Should a professional service fee with the courtesy reduction total less than $10.00 then the $10.00 minimal fee charge would over ride the courtesy reduction, unless it was predetermined that the examination would be performed "without charge".

MATERIALS:

1. All students, benefits eligible employees, and retirees in and from the College of Optometry and their immediate family members are eligible to purchase spectacles and contact lenses for personal use at College invoice plus a dispensing fee.

2. Relatives of UHCO faculty, staff, and students who are not immediate family members may purchase spectacles and contact lenses from the College of Optometry at a 20% reduction from the usual charge.

3. Full time University and College students at all campuses (UH, TSU, Rice, HBU, A&M, HCC, etc. - not their immediate family), and Health Profession Students are eligible for a 10% reduction off spectacles and contact lenses for personal use. Health Care Practitioners will be extended the same courtesy on materials.

4. University of Houston and Texas Southern University benefits eligible faculty, staff, and other employees and their immediate family members may purchase spectacles and contact lenses from the College of Optometry at a 10% reduction from the usual charge. University of Houston retired faculty and staff will be extended the same courtesy on materials.

5. UHCO work-study students who have been employed for a minimum of 90 days may purchase spectacles and contact lenses for personal use, one time only, at the College invoice plus a dispensing fee.

NRH:djj

PROFESSIONAL COURTESY REDUCTIONS CHART

|PROFESSIONAL COURTESY REDUCTIONS CHART | | |

| |PROFESSIONAL FEE |MATERIALS REDUCTIONS |

| |REDUCTIONS *** | |

|UHCO Students and their immediate family * |100% |Invoice cost + disp. fee |

| |All Services |PERSONAL USE ONLY |

| | | |

|UHCO Benefits eligible employees, UHCO retirees |100% |Invoice cost + disp. fee |

|In & from UHCO, & their immediate family * |All Services |PERSONAL USE ONLY |

| | | |

|TEXCOP students- (NOT FAMILY) |100% |Lab cost of frames & lenses |

|One exam only, at off peak times in Family Practice |C.L. UH student cost |plus disp. fee. Personal use only |

| | | |

|Work-study/Part-time (NOT FAMILY) |100% |Lab cost of frames & lenses |

|One exam only, at off peak times in Family Practice |C.L. included |plus disp. fee. Personal use only |

| | | |

|Not immediate family of UHCO faculty, staff & |50% |20% |

|Students ** | | |

| | | |

|ECAP Program — Must meet qualification set by |Limited choice of frames |

| |(see Mark Rice) |

|UEI administration (see Clinic Business Office) | |

| | | |

|Full-time Texas College Students ∙ . – Not technical |40% |10% |

|Or trade schools, etc. (with CURRENT ID card) | | |

| | | |

|UH, TSU & Benefits eligible faculty, staff and |40% |10% |

|Students-immediate family of faculty/staff Only |EXCEPT: |

| |DEVELOPMENTAL & NOVA VISITS |

|NOT immediate family of students | |

| | | |

|Health Professionals and students with current |40% |10% |

|ID | | |

| | | |

|UH Retired Faculty and Staff with current ID |40% |10% |

|DOES NOT INCLUDE FAMILY MEMBERS |EXCEPT OD/MED | |

| | | |

|Prompt Pay |20% if paid the day services are rendered |

| | | |

|City of Houston (per RB) | |10% |

| | | |

|∙ Full-time (undergrads) & Grad students-current ID’s | | |

|* spouse, children, parents, siblings, step children, and step parents. |

|** in-laws, nieces, nephews, aunts, uncles, grandparents, and grandchildren. Fiancées do not apply, nor cousins. |

|These fee reductions only apply if no insurance is available |

| | | |

U N I V E R S I T Y E Y E I N S T I T U T E

FEE ADJUSTMENT FORM

(APPROVED BY AUTHORIZED INDIVIDUALS ONLY)

DATE:

ACCOUNT #: FILE #:

PATIENT NAME:

ADDRESS: DOB:

CITY/STATE/ZIP:

ADMINISTRATIVE ADJUSTMENTS

REASON FOR ADJUSTMENT:

% COURTESY REDUCTION: ON SERVICES OR PROCEDURES.

SERVICE: APPROVED BY:

No reduction on materials.

Glasses (Green Dot Series Only): Single Vision $49, Bifocal $69, Trifocal $79.

White – Patient Folder Yellow – Executive Director of UEI

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