Forms and Information

On your first visit to the office, you will need to complete a policy form, an insurance form, a medical history form, and a privacy acknowledgement form.  You can view, download, and print them on any computer in Adobe PDF format by clicking on this link: Forms.  This will allow you to finish the forms at your convenience and save you time in the office by bringing them with you.  If you do not have an Adobe Acrobat Reader on your computer, you may download it free from the Adobe Website.  The content of the office policy form is listed below for your review.

OFFICE AND FINANCIAL POLICIES

GENERAL INFORMATION

Payments may be made by cash, check, credit card, or debit card.  However, we do NOT accept American Express.

If your child is interested in contact lenses, please let us know in advance so that we may allot extra time for a fitting.  We do not give contacts to children under 12 years of age except in for special medical conditions such as aphakia.  Typically, contacts are not covered by insurance.

An initial office visit, or full yearly check will require at least 60-90 minutes and requires the use of dilating eye drops.  These will make the patient’s vision blurred and light sensitive for many hours.  We make every effort to run on time and we do not double book patients.  However, your time in the office may be longer because of situations beyond our control.  For example, there may be an emergency, or a child may have an extremely complex problem which we were not aware of when the appointment was made, or there may simply be a large number of uncooperative young patients who take longer than expected to be examined.

To be fair to other patients, we will not see anyone more than 20 minutes late for the appointment.  If you will be delayed, please contact us so that we can make arrangements to accommodate you and minimize disruptions to others.

INSURANCE AND FINANCIAL INFORMATION

If you have medical insurance, we are committed to helping you work within the framework of your policy.  However, it is important that you realize it is your responsibility to understand the rules of your plan.  Any questions regarding coverage must be directed to your insurance carrier or to the benefits coordinator at your place of employment.  Your insurance coverage is a contract between you and your insurance carrier, not with the physician.  We do not control what benefits you have.  We will work according to the rules of your insurance carrier as we are instructed to do, but we have no control over what the carrier considers a covered benefit.

Participating Plans:  If you are seeing us as a participating provider in your plan, there are several important points to be aware of:

• If you have a diagnosis which your insurance carrier does not consider “medical,” and you do not have vision coverage, your claim may be denied.  In such a circumstance, you will be responsible for payment at our regular fee schedule even if you had a referral.  We cannot fabricate a non-visual diagnosis to insure payment by the insurance carrier.

• Deductibles are the patient’s responsibility.  The deductible is determined by the contract you have with your insurance carrier.  We do not know how much each person’s deductible is and how much has been met at the time of your visit.

• Co-insurance and co-payments are the patient’s responsibility.  Co-payments are due at the time of the visit.  We will not see any patient without the co-payment being made at the time of the visit.

• We submit claims to your insurance carrier for you, but you are responsible for responding to any requests from the insurance carrier for further information.  Not doing so will result in a claim denial and you will be responsible for payment.

• It is your responsibility to obtain referrals if required to do so by your insurance plan.  We must have a referral at the time of the visit.  We cannot accept “back dated” paper referrals.  Many insurance carriers use electronic referrals.  In such a circumstance the referral must be in the system prior to your visit.  We cannot have you call your primary care physician to obtain a referral when you arrive at the office.  This is disruptive and delays other patients.  Additionally most primary care offices will not honor such a request.

• We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of the visit, the financial responsibility for payment is yours.

• If you have had any changes in your insurance coverage – even if there is only a small change in the co-payment amount or a change in the expiration date of the policy – you must notify us.  Even a small discrepancy on the claim form such as the wrong end-date of coverage may lead to a claim denial.

• If insurance payments are sent to you erroneously, you are responsible for forwarding them to our office.

Non-participating Plans:  If you have insurance coverage, but we do not participate in your insurance plan, payment for services is due at the time of service.  It will be your responsibility to forward any claims for reimbursement on to your insurance carrier.  We will provide you with a receipt detailing the diagnosis and codes charged for the visit.

Responsible Parent:   In a situation where the patient’s parents are divorced or separated, our policy is that the parent bringing the child for an exam is the responsible party.  We cannot bill the other parent.  This has caused too many problems in the past and we cannot become entangled in legal battles between two parties.

MINORS

Someone with legal authority must accompany all patients under 18 years of age.  You cannot send a child with a neighbor, sibling, au-pair, nanny, grandparent, or other adult without a signed note giving your permission for said person to act on your behalf.  Whoever is accompanying the patient will be given information about the examination, and it is up to them to communicate this information to the parent or legal guardian.  We cannot call the parent or legal guardian at the time of the visit to explain the entire exam and findings over the phone.  This is disruptive and delays other patients.

MISSED APPOINTMENTS

We understand that people may have emergencies or may simply make a mistake and forget appointments.  However, if more than one appointment is missed without a 24 hour notice (except in the event of an emergency) this will incur a $25 “missed appointment” fee.  Any patient who misses more than three appointments without notice will not be given another appointment.