FINANCIAL POLICY

Thank you for choosing Samida Medical Group, Inc., DBA EyeSight MD as your medical provider.  We are committed to providing you with the best possible medical care.  We are sure you understand that payment for these healthcare services is your responsibility.  The following information outlines your financial responsibilities related to payment for the professional services rendered.

 Please initial next to each statement showing that you have read it and then sign page 2.

CO-PAYMENTS AND DEDUCTIBLES: You are responsible for your deductible and co-insurance/co-payment.  Co-payments are due at the time of service. Co-insurance, deductible and any additional co-payment amounts will be billed to you and are due upon receipt of our statement.  Any accounts not paid for in full within 60 days of your first statement may be considered for assignment to a collection agency. We accept cash, check, or credit card (Visa, MasterCard, AMEX and Discover). If you are a minor (18 years or younger), the parent or guardian is responsible for payment of the account in accordance with the policy outlined above.

MEDICARE: As of 12/2024, we are no longer a participating provider for Medicare and are considered out of network. We do not bill any out of network claims.

CONTRACTED HMOs & PPOs: You are responsible for any applicable deductibles or co-insurance amounts. Services not covered by your plan will be billed to you. Authorization is your responsibility prior to service. If an authorization is not in place, your appointment may need to be rescheduled.

NON-COVERED SERVICES: Most insurance companies differentiate covered from non-covered services. Non-covered services are also referred to as cosmetic, not medically necessary, or investigational/experimental. _____ If we provide a service to you that is not covered by your health plan, you will be responsible for the charge of $50 or any associated co-payments.  This situation most commonly applies to refractions and sensorimotor evaluations (procedure codes 92015 and 92060 respectively). Refractions if not covered or considered non-covered services are $50. Your signature, below, constitutes the agreement to pay for such services.

CANCELLATION AND MISSED APPOINTMENT POLICY:

_____ Eyesight MD is committed to providing exceptional care. Unfortunately, when one patient cancels or misses an appointment without giving enough notice, they prevent another patient from being seen. Please call us at 714-289-2389 by 12:00 p.m. on the day prior to your scheduled appointment to notify us of any changes or cancellations. If prior notification is not given, you will be charged $75.00 for the missed appointment.

SELF PAY: You are required to pay for each service in full at the time of services.

CONSENT TO MEDICAL AND SURGICAL PROCEDURES:  I consent to the procedures which may be performed during this, or future visits, including emergency treatment or services, and which may include but are not limited to laboratory procedures, radiology examination, photography, medical treatments, surgical procedures, anesthesia, or hospital services rendered to the patient under the general and special instruction of the patient’s physician or surgeon.

RELEASE OF INFORMATION:  

_____ I hereby authorize the release of medical records and/or statement of account to my insurance company to determine benefits for services rendered.

ASSIGNMENTS OF BENEFITS:

_____ I hereby assign to EyeSight MD any insurance or other third-party benefits available for health care services provided to me. I understand that EyeSight MD has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to EyeSight MD. I agree to forward to the Practice all health insurance and other third-party payments I receive for services rendered to me immediately upon receipt.

By signing, you acknowledge the authorization for the RELEASE OF INFORMATION and ASSIGNMENTS