PAYMENT POLICY: It is customary to pay for professional services when rendered. For your convenience, we accept major credit cards, checks, cash or care credit.

INSURANCE: Please read and sign below if you have insurance with Medicare, Medicaid, an HMO/PPO/POS or State Agency or Worker’s Comp, and the Physician is contracted with your carrier. Present your insurance card along with any required referrals/authorizations to the receptionist/registrar.

MEDICAL BENEFITS ASSIGNMENT AND RELEASE OF MEDICAL BENEFITS INFORMATION AGREEMENT: I request payment of my authorized insurance benefits be made for charges on my behalf to Houston Eye Associates for any unpaid medical procedures performed now or in the future. I also authorize Houston Eye Associates to release medical information to my insurance company(ies) or agent now or in the future, for claim consideration purposes. I understand that payment for services does not ultimately remain my responsibility.

NON-COVERED SERVICES: The filing of a claim for any service rendered DOES NOT GUARANTEE PAYMENT from your insurance company. You will be financially responsible for these services. Also, having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Secondary insurers will pay as a function of what your primary carrier pays. We may bill your secondary as a courtesy. You are responsible for any balances due after your insurances(s) have cleared.

DIVORCE DECREES: This office is NOT a party to your divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for minors rests with the accompanying adult.

MINOR PATIENTS: For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card or payment by cash or check at the time of service has been verified.

NO SHOW POLICY: We understand that sometimes you may need to cancel your appointment. Please cancel your appointment at least 24 hours in advance, when possible. This allows us to accommodate other patients who are seeking an appointment. If you do not cancel your clinic appointment, this will be documented as a “No-Show” appointment and you will be charged $45. If you do not cancel your surgery appointment 24 hours in advance and do not present to the office for your surgery this will be documented as a “No-Show” appointment and you will be charged $200.