Financial & Office Policy
Effective 06/01/2023: Self-Pay rate for Routine Vision has increased from $99 to $149, and our Medical Self-Pay exams remain at $150.
Thank you for choosing the Virginia Eye Institute (VEI) for your healthcare needs. This formdescribes patient and insurance responsibility for services rendered. As either the patient or theresponsible party of the patient, your understanding of and compliance with our consent for treatmentand financial policy is important. For purposes of clarity, the term “I” is used interchangeably to meanthe patient receiving medical services, the guardian of the patient, or the person financially responsiblefor any cost incurred by the patient. Please read the statements below and ask the staff any questions you may have.
Consent for Treatment
I authorize VEI to provide medical treatment to myself and/ or those for whom I am a legally authorized representative. In the event that any VEI employee is exposed to my blood or other potentially infectious bodily fluids, I understand I am deemed to consent to 1) testing for infection with human immunodeficiency virus, Hepatitis B and C viruses, and 2) release of those test results to the employee exposed pursuant to Virginia Code 32.1-45.1.
Legal consent for medical treatment of a minor child (patients under 18 years of age) must be made by a parent, guardian, or other legally authorized representative. If a parent or legal guardian is unable to accompany their child to their appointment, they must provide authorization allowing another designated adult to accompany the child to appointments and for that adult to consent to the child’s medical care. Emancipated and/or married minors can legally consent to their medical treatment without the involvement of others. If a parent has sole medical decision-making rights for a child, it is their responsibility to provide the legal documents, otherwise VEI will presume both parents have a right to consent to the child’s medical treatment and access the child’s medical records.
Financial Responsibility
I request that payment of authorized Medicare, Medicaid, or applicable private insurance benefits, if applicable, be paid directly to VEI for services provided by Virginia Eye Institute physicians and employees. I authorize VEI to release necessary medical information to my insurance company, its agents, or to any third-party payer in order for payable benefits for these services to be determined.
I understand that I am financially responsible for all fees not covered by my insurance or any other third-party payer. My insurance policy is a contract between me and my insurance carrier, and I am responsible for providing VEI with the correct insurance information by the time of service, or I may be responsible for the total charges. If my insurance policy is not active or in-network with VEI, I must pay in full for services at the time of service. If I have no active and in-network insurance, I am responsible for my entire visit and will be considered Self-Pay, requiring payment for all services at the time of service. If my insurance is accepted, I must pay for all applicable copayments, coinsurance, and deductibles at the time of service.
04.18.2025
If my deductible has not been met at the time of service, I am required to pay a deposit of $200.00. Once my insurance has been billed, any remaining balance will be my responsibility. For self-pay patients, an initial deposit of $200.00 is also required. Any remaining balance for all services rendered will be billed to me, and it is my responsibility to cover these charges.
Payments can be made by cash, check, or credit/debit card (MasterCard, Visa, Discover, American Express, ApplePay, GooglePay, SamsungPay). There will be a $35 fee assessed for any check returned to VEI’s bank as unable to process for any reason. I have the option to keep a credit card on file for automatic debits of any balance.
If I am unable to pay for copays or non-covered charges at the time of service, my appointment may be rescheduled.
Though VEI will file my insurance claims (with VEI participating insurance plans), I am ultimately responsible for full payment of all charges not covered by insurance. Should my insurance company failto pay the claim for services rendered by VEI, I may be responsible for all charges submitted to theinsurance carrier.
Certain insurance policies necessitate a referral from a Primary Care Physician before a patient can be seen by a VEI physician. It is the patient’s responsibility to obtain these referrals. I understand that if I fail to secure the required referral, I will be responsible for all charges.
Please be advised that you will be responsible for any additional fees associated with the completion of forms not covered by insurance. This includes, but is not limited to, fees for DMV, FMLA, and Disability forms. These fees are necessary to cover administrative costs and ensure timelyprocessing of your requests.
Patients with open balances of over $500.00 will be required to enroll in a payment plan and keep a credit card on file for payment arrangements. If patients are having difficulty making payments on open balances, they should contact the VEI Revenue Cycle Department at (804) 287-4920 to establish afair and appropriate payment plan. In such cases, patients may need to provide financial income information to help VEI determine a suitable monthly payment.
Additionally, I acknowledge that should I need surgery, Virginia Eye Institute requires payment of the total share of the out-of-pocket costs at least ten (10) days before the scheduled surgery date.
Should collection proceedings or other legal action become necessary to collect an overdue account, VEI has the right to disclose all relevant personal and account information to an outside collection agency. I agree to pay all collection fees and reasonable attorney fees up to 33 1/3% of the total unpaid balance, plus court costs and filing fees. If the practice is awarded judgment, I will pay 1.5%interest per month (18% per year) starting from the judgment date.
No Surprises Act
04.18.2025
Under the No Surprises Act, uninsured and self-pay patients have the right to receive a GoodFaith Estimate (GFE) before the scheduled service is rendered. The Good Faith Estimate provides the expected patient financial responsibility for scheduled or non-emergency items or services at least one(1) day before the items or services are provided. If the actual bill exceeds the Good Faith Estimate by more than $400, the patient has the right to dispute the charges.
Missed Clinic Appointments*
Please help us preserve access to our providers’ schedules and offer timely appointments to all patients by keeping your scheduled appointments. In the event you are unable to keep your scheduled appointment, please give VEI at least 24 hours’ notice.
Aesthetic Center appointments: I understand that should I fail to notify VEI within 24 hours of my appointment that I will not make my scheduled appointment; I am responsible for a missed appointment fee of $50. I understand that each provider at VEI reserves the right todiscontinue the provider-patient relationship, if there becomes a pattern of missed appointments and/orcancellations with less than 24 hours’ notice.
All other clinic appointments: I understand that should I fail to notify VEI that I will not make my scheduled appointment; I am responsible for a missed appointment fee of $50. I understand that each provider at VEI reserves the right to discontinue the provider-patient relationship, if there becomes a pattern of missed appointments and/or cancellations with less than 24 hours’ notice.
MISSED CLINIC AND SURGERY APPOINTMENT CHARGES ARE THE RESPONSIBILITY OF THE PATIENTAND WILL NOT BE SUBMITTED TO ANY INSURANCE CARRIER.
Prohibitions
Consistent with state and federal privacy laws, and as a condition of treatment, audio and video recordings are not permitted inside any VEI facility. Should anyone be observed recording or taking photographs with a cellphone or other device, the individual will be asked to immediately erase the audio, video, or photographs to protect the privacy of other patients and VEI associates.
Photographs or recordings of a doctor may be taken only with the doctor’s permission and only if no other patients are captured in the images or recordings.
VEI Code of Conduct
04.18.2025
It is Virginia Eye Institute’s goal to provide world class care while maintaining a healthy environment, where staff, patients, and visitors feel safe, respected, and valued. To foster such an environment, VEI has developed a Code of Conduct that we expect everyone to adhere to when interacting with others. Our complete Code of Conduct is posted in our facilities and on our website. Failure to adhere to VEI’s Code of Conduct may result in mediation, termination of the provider-patient relationship, and/or involvement of law enforcement.
