Retina & Vitreous, LLC
We are committed to providing you with the best possible medical care. We are willing to work with you if you have special financial needs. Our practice firmly believes that a good physician/patient relationship is based upon understanding and communication.
Please bring your medical insurance card(s) with you for each visit. We do not bill to vision insurance.
It is your responsibility to provide current insurance cards at time of service, you may be responsible for the charges if you do not provide them to us in a timely fashion.
In order to prevent fraud, you will be asked to provide a valid US government issued photo ID at your
Without a valid ID, you will be considered a self pay patient and will be responsible for all charges. Payment is due at time of service.
Our office participates in a variety of insurance plans. It is important for you to verify if our doctors are providers in your plan. It is your responsibility to get a referral if your insurance requires one. If you do not, you will be responsible for all charges and considered a self pay patient.
Commercial Patients-In Network
You agree to pay your copay at time of service. You agree to pay any coinsurance or deductibles that your insurance states to us is patient responsibility.
Out of Network Commercial Patients
You are considered a self pay patient in this office and the self pay policy will apply to you.
Self Pay Patients
A deposit of $350.00 is required at your first visit. Your charges that day may be more, based on diagnostic testing or any treatment. We can offer you a prompt pay discount of 20% if entire charges are paid within 10 days. The discount will be applied at time of completed payment.
Please bring a copy of your Medicare card, your supplement card, and your drug card. We will file with Medicare and the supplement and agree to accept Medicare's assignment for our fees. Any amount we bill you is after your insurances have paid their portion and have informed us of what to bill you. You agree to pay your portion.
If you have a replacement plan for Medicare, we will need a copy of that card. This replaces
your Medicare card. Many replacement plans have a copay which you agree to pay on your date of service and additional out of pocket coinsurance for procedures and diagnostic testing. You will be responsible also for this portion that your plan puts as patient responsibility.
For patients 17 years old and younger
For patients 17 years and younger, a parent or guardian must accompany them and sign below (exception: declared emancipated minors). It is the parent's or guardian's responsibility to provide insurance cards and payments at time of service.