• Thank you for choosing Retinal Consultants of San Antonio as your healthcare provider.

    We appreciate your trust in us and the opportunity to provide you the best possible retinal care.

    PATIENT PAYMENTS

    Payment (co-payments, co-insurance, and/or deductibles) is due at the time of service. If you have an outstanding balance, please make sure you are prepared to pay it at the time of your visit. We accept cash, check, or a credit/debit card to pay your account. We can keep a current credit card on file. Our software securely encrypts and stores your credit card information displaying the last 4 digits of your credit card number only. The credit card will be encrypted and stored into your secured patient file, and used to cover your balance according to the terms of this policy.

    FIRST STATEMENT

    Your insurance policy is a contract between you and your insurance company. This contract requires we collect certain co-payment or prepayment amounts depending on the type of insurance and insurance carrier at the time of service. Regardless of your insurance status, when we determine you owe a balance, we will mail a statement to the mailing address you provided to us. If your address changes, you are responsible for notifying us. Payment is due upon receipt of the statement. Please contact our office as soon as possible after receipt of your statement, if you have any questions or wish to discuss the outstanding balance. If needed, we can set up a payment plan with a valid credit card. One-third (1/3) of the total balance is due the first day of the payment plan. The credit card used will automatically be charged for the second and remaining third balance owed monthly. We require payment plans to be arranged before your bill is 30 days old. If your insurance pays us after that time, you will be reimbursed.

    SUBSEQUENT STATEMENTS AND UNPAID BALANCES

    If your account remains unpaid, subsequent statements will be sent to the address we have on file.Although Retinal Consultants of San Antonio does not charge interest for amounts past due and left unpaid by the insurance or the patient, a $5.00 statement fee will be included for additional statements sent on unpaid balances. When your balance is 90 days past due, your credit card will be charged for the full amount owed. If declined, your account will be frozen and turned over to an outside collection agency for non-payment. We will continue to provide 30 days of emergent care to give you time to find another physician. In this event, the Guarantor of the account agrees to pay all fees acquired by the collection agency.

    INSURANCE COVERAGE

    Although we make every effort to verify your coverage, we cannot guarantee that the information given to us by your insurance carrier is correct. It is your responsibility to know what services may or may not be covered by your insurance. We encourage you to refer to your benefits manual if you have any questions about covered services. Please notify the office of any changes to your insurance benefits.

    At the time of your appointment, we will charge you based on our most up-to-date information from your insurance plan. Due to payments from other physicians or facilities being processed on your account, we may need to reimburse you or collect more later.

    If your insurance delays payment, you will be responsible for paying, in full, the charges. You may obtain reimbursement from your insurance provider directly. If we are given incorrect insurance information that delays payment beyond the limit to file the claim, you will be responsible for the charges.

    THIRD PARTY PAYORS

    Our office does not bill third party payors, such as motor vehicle accident claims or worker’s compensation claims. If you wish to see our doctors for a visit that would normally require us to bill a third-party payer, you are required to pay for all services rendered in full as a self-pay patient. We will then provide you the information you need to submit the claim yourself.

    ADULT ADVOCACY

    As an advocate for our patients, Retinal Consultants of San Antonio will not intervene in any divorce dispute or financial responsibility dispute between married, legally separated, or other responsible parties. We will send statements to the address provided; however, we cannot look to more than one party for financial responsibility.

    MISSED, LATE OR CANCELLED APPOINTMENTS

    We require a 24-hour notice for cancellation of scheduled appointments, and a 2-hour notice for an emergency appointment made on the same day. This courtesy will allow other patients to be seen in a timely manner. If you are more than 15 minutes late for your scheduled appointment, the physician will determine whether the appointment will need to be rescheduled. Missed appointments will be subject to a NO-SHOW fee as follows:

    1st Missed Appointment $25
    2nd Missed Appointment $50
    3rd Missed Appointment $100
    After the 3rd No Show, you may be asked to find another healthcare provider.

    FEES

    Retinal Consultants of San Antonio reserves the right to charge the following fees:

    Medical Records $25.00
    No Show Fees $25/$50/$100
    FMLA / Disability Paperwork $25.00
    Statement Fee $5.00

    We welcome the opportunity to discuss any aspect of our financial policy. Please ask to speak with the Office Manager if you have any questions, comments, or concerns. Thank you for your support and we look forward to serving you in the future.

    Our office makes a great effort to have insurance companies pay the cost of your care in a timely manner. However, due to the recent changes brought on by the Affordable Care Act, this is becoming more challenging. We have, therefore, implemented a new Financial Policy that we ask you to review before signing below. A copy of this policy will be provided to you upon request. If you have any questions, please ask to speak with the Office Manager.

    A few items in the Financial Policy have been outlined for you.

    Payment (co-payments, co-insurance, and/or deductibles) are due at the time of service.

    We can keep a current credit card on file.

    Payment is due upon receipt of the statement.

    A $5.00 statement fee will be charged for additional statements sent on unpaid balances.

    Missed appointments will be subject to a NO-SHOW fee.

    If the insurance information you provide delays payment, you will be asked to pay, in full, billed charges and seek reimbursement from your insurance provider directly.

    I have reviewed the Financial Policy information and provide my consent regarding any and all the issues as stated in the policy and above.

    I understand a copy of this policy will be provided to me upon request.