Morgan Vision Care Financial Agreement and Release of Information

As a courtesy to our patients. Morgan Vision Care, PC will verify your benefits and eligibility as well as file your insurance claims for you. This includes Medicare, Medicaid, Tricare (Champus), Anthem and Optima, as well as any commercial plans we participate with. If you choose not to have us file your claim for you, then you accept full financial responsibility at the time services are rendered. Please remember that your insurance is a contract between you and your insurance company. You are ultimately responsible for knowing your benefits and eligibility for services rendered prior to receiving them. All co-pays and deductibles are due at the time of service. It is the patient's responsibility to update us when there are any insurance changes, failure to do so will result in the patient being billed for 100% of the service charge.

There will be a $50.00 fee for all returned checks.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. Generally, you will be responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Statements are mailed out on a monthly basis. You will receive a bill from us whenever your insurance company pay on a charge and leaves a balance due which is your responsibility. We ask that bills be paid within 30 days, unless prior payment arrangements have been made with our billing personnel. If you are unable to pay your balance within 30 days, we ask that you contact our billing personnel to make necessary arrangements.

If for any reason, you do not receive a statement, it is your responsibility to contact our office to ensure that your account has been satisfied by your insurance company. In the event that you move or have a change of address, it is your responsibility to inform us of your new address. Statements returned to us by mail will be forwarded to collections if no forwarding address can be obtained. There will be a 1.5% monthly service charge on unpaid balances over 30 days old. If the account is not satisfied within 90 days, it will be forwarded to a collection agency. The patient will be responsible for any collection/attorney/court fees, if applicable, associated with collecting the physician's fee.

Morgan Vision Care, PC maintains an electronic health record of all patient treatments, demographic and billing information. Please be assured your records are kept secured in our electronic system and can only be accessed by our Morgan Vision Care, PC staff for purposes of your treatment. Our office maintains patient records for at least 5 years from the last patient encounter. After that time, our office may destroy your records in a manner which protects patient confidentiality.

I hereby attest that I have read the above information in its entirety and completely understand its context and acknowledge by my signature below that I agree to the terms and conditions set forth above.