Patient Financial Responisiblity Agreement

Patient Responsibility

Any fees collected at the time of service and any quotes regarding such fees are estimated based on the information available to us at the time of service. We rely on information provided by the responsible party regarding insurance coverage, information from the responsible party's insurance company, and procedure fees associated with the CPT codes scheduled/reserved and provided to us by your surgeon. This estimate does not include the fees for the physician or anesthesiologist. There may be additional charges should your surgeon perform a procedure that is different from, or in addition to what was scheduled for implants or other services which were not scheduled or quoted prior to surgery.

It is the patient's responsibility to understand their individual insurance benefits.

Payment Arrangements

Payment arrangements are available. Please ask about this option. Any payment arrangements must be made prior to services being provided.

Billing Practices

Premier Eye Surgery Center will bill the responsible party's insurance company for facility charges. Premier Eye Surgery Center will also collect any co-payments, coinsurance, and/or deductibles at the time of service. The responsible party will be billed for any remaining charges not covered by insurance, including co-payments, co-insurance and/or deductibles. Additionally, the responsible party will be billed for facility charges in full should the insurance company deny coverage due to lack of referral, no preauthorization, lack of proper reporting of incident/accident or lack of individual coverage, where applicable.

Collection Activity

Consent to Telephone Calls for Financial Communications

With regards to services rendered and/or my related financial obligations, I expressly agree and consent that Premier Eye Surgery Center and any associated affiliate / vendor providing quality improvement, customer service, billing or collection services may contact me by any method of contact (such as a telephone call utilizing an automated dialing device, dialing services, prerecorded message or texting) to any telephonic number that I have provided to the surgery center, or has been obtained by the surgery center or any of its associated affiliates / vendors or at a number forwarded or transferred from that number, including mobile telephone numbers.

I ___ CONSENT / ___DO NOT CONSENT to the above statement.

Any account balance that is not paid within 90 days of the date of service may be forwarded to an outside agency for collection follow-up with a 30% collection fee. Any account balance that remains unpaid after this transfer may be eligible for reporting to a credit bureau. Should litigation be necessary to collect an outstanding balance owed, the responsible party agrees to pay all costs of collection including, but not limited to, collection fees, attorney fees, interest, and court costs.

Please contact Premier Eye Surgery Center’s Business Office at 303-801-3393 with questions.