Effective 06/01/2023: Our SELF-PAY RATE for Routine vision has increased from $99.00 to $149.00. Please review the below information to familiarize yourself with the potential appointment types to identify self-pay patients. As a note all routine vision self-pay exams are changing to $149.00 all medical self-pay exams will remain the same at $150.00 at check in and the remainder collected for any additional tests performed after exam.
Thank you for choosing the Virginia Eye Institute (VEI) for your healthcare needs. This form describes patient and insurance responsibility for services rendered. As either the patient, or the responsible party of the patient, your understanding of and compliance with our patient financial policy is important. For purposes of clarity, the term “I” is used interchangeably to mean the patient receiving medical services, the guardian of the patient, or the person financially responsible for any cost incurred by the patient.
Please read the statement below and ask the staff any questions you may have, then sign where indicated. The original will be maintained in your file and a copy will be provided to you upon request.
- CONSENT FOR TREATMENT I authorize VEI to provide medical treatment to myself and/or my dependent. In the event that any employee is exposed to my blood and/or body fluids, I consent to laboratory testing of my blood and/or body fluids. I consent to laboratory testing of my blood for Hepatitis B and/or C and AIDS antibody and agree for the results of such test to be released to the person who has been exposed.
- RELEASE OF MEDICAL INFORMATION 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.
- FINANCIAL RESPONSIBILITY I understand that I am financially responsible and agree to pay all of the fees that are not otherwise paid by or billed to my insurance or any other third party payer. I understand that, if my insurance policy is not active or accepted, I must pay in full today for all services rendered. I also understand that if my insurance is accepted, I must pay all applicable insurance copayments and coinsurance today.
I understand that if my deductible has not been met at the time of service, I am required to pay $150 deposit at time of service. Once my insurance has been billed, any balance will be my responsibility.
I understand that though VEI will file my insurance claims, I am ultimately responsible for full payment of all charges not covered by insurance(s). Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient’s responsible party understands that VEI has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patient’s responsible party, further understands and agrees to pay all collection fees and reasonable attorney fees in the amount up to thirty-three and one-third percent (33 1/3%) of the total unpaid balance due, plus court costs and filing fees. I understand and agree that should the practice be awarded judgment relating to this agreement or any debt incurred thereof, I will pay interest in the amount of one and one-half percent (1 ½%) per month, eighteen percent (18%) per annum, beginning on the date of judgment.
I understand that I am responsible for my entire visit if I have no insurance and will be considered Self-Pay. I am required to pay a $150 deposit upon arrival and any additional amount that may be due at check-out.
- NO SURPRISES ACT: The No Surprises Act of 2022 requires that patients receive a Good Faith Estimate of the amount patients are to be billed for scheduled or non-emergency items or services at least one (1) day prior to the time such services are rendered. All healthcare providers are required to give patients, including those undergoing cosmetic procedures, an estimate of their personal cost for scheduled items or services. To view a PDF of our No Surprises Act Notice, click here.
I understand that whether or not I have insurance, if the estimate I receive for the anticipated items and services exceeds the amount billed by more than $400, I have the right to dispute the bill.
I further understand that it is Virginia Eye Institute’s policy that the patient’s share of the total cost be paid at least ten (10) days prior to the scheduled surgery date.
- INSURANCE POLICY: Your insurance policy is a contract between you and your insurance carrier. You are responsible for providing VEI with the correct insurance information no later than at the time of service or you may be responsible for the charges in full.
I understand that should my insurance company fail to pay the insurance claim for services rendered by VEI, I may be responsible for the entire charges submitted to the insurance carrier.
- ASSIGNMENT OF BENEFITS: I request that payment of authorized Medicare, Medicaid or applicable private insurance benefits be paid directly to VEI for services provided by Virginia Eye Institute physicians and employees.
- CO-PAYMENTS, DEDUCTIBLES, & CO-INSURANCE: I understand that I am expected to pay AT THE TIME OF SERVICE all amounts not covered by my insurance policy. Such amounts include co-payments, co-insurance, and potentially deductibles. Payments may be made by cash, check, and/or credit card (MasterCard, Visa, Discover, American Express, ApplePay, GooglePay and SamsungPay).
I understand that if I have a high deductible insurance plan, and if the deductible is not met, I am required to pay a $150 deposit at the time of service. Once my insurance has been billed, any balance will be my responsibility.
I further understand that if I am unable to pay for co-pays and/or non-covered charges at the time of service, my appointment may be rescheduled.
- REFRACTION: Refraction is the measurement of the focus error of an eye. It determines the set of lenses that will best focus the light entering the eye. The results of a refraction are used to: (a) determine the health and visual potential of an eye; (b) aid in performing tests such as visual fields; and (c) to prescribe glasses and/or contact lenses. Refractions are considered to be a “non-medical” service by most insurance companies and therefore a non-covered service.
I understand I am responsible for a REFRACTION FEE of $70.00 at time of service, if performed as part of my examination. Should I wish to be billed for this service instead of paying at time of service, I understand that the REFRACTION FEE WHEN BILLED is $70.00.
- REFERRALS: Some insurance policies require a “referral” from a Primary Care Physician before being seen by a VEI physician. The patient is responsible to obtain referrals.
I understand that, should I fail to obtain a required referral, I am required to make a $150.00 deposit at time of registration as well as be responsible for any additional charges that might result.
- SELF-PAY PATIENTS/PATIENTS WITHOUT INSURANCE COVERAGE: Patients without insurance coverage are expected to pay a $150.00 deposit at time of registration as well as any additional charges at the end of the visit upon checking out.
I understand that these payments are due in full on the date of service.
- SELF-PAY PATIENTS – ROUTINE VISION EXAM – NON-MEDICAL: Patients without insurance coverage are expected to pay a $149.00 at time of registration as well as any additional charges at the end of the visit upon checking out.
I understand that these payments are due in full on the date of service.
- OPEN BALANCES: Patients with open balances on previous office visits or surgical procedures will also be asked to pay 50% of any open balances at the time of the new visit. Patients who are unable to pay the 50% on any open balances may be asked to reschedule their visit. Exceptions to the 50% may only be made upon approval through the Business Office, the Lead Patient Care Representative (Supervisor), the Associate Director of Revenue Cycle Management, or the Director of Revenue Cycle Management.
- BILLING OFFICE: Patients who are experiencing difficulty in making payments on open accounts are asked to contact a VEI Patient Financial Advocate at (804) 287-4213 in order to establish a fair and appropriate payment plan. Patients may be asked, in these circumstances, to provide financial income information, which VEI can use in determining an appropriate and fair monthly payment.
- MISSED CLINIC APPOINTMENTS*: Please help us serve you better by keeping scheduled appointments. In the event you are unable to keep your scheduled appointment, please give a 24-hour notice.
I understand that, should I fail to provide this 24-hour notice of cancellation, I am responsible for a missed appointment fee of $50.
- MISSED SURGERY APPOINTMENTS*: In order for VEI to provide cost-effective services, we need to make efficient use of expensive resources such as our Ambulatory Surgery Center. Accordingly, it is essential that patients notify VEI of a decision to cancel a scheduled surgery no less than SEVEN (7) DAYS BEFORE a surgery appointment time.
I understand that should I fail to show for a scheduled surgery (including laser and cosmetic procedures) appointment without first notifying VEI of my decision to cancel at least SEVEN (7) DAYS IN ADVANCE – in other words, if surgery/laser is scheduled on a Monday, I must cancel by the previous Monday – I am responsible for a “No Show” fee of $150.
* THESE CHARGES ARE THE RESPONSIBILITY OF THE PATIENT AND WILL NOT BE SUBMITTED TO ANY INSURANCE CARRIER.
- RETURNED CHECKS: There will be a $35 fee assessed to your account for any check returned to our bank as unable to process for any reason.
- PROHIBITIONS: Consistent with state and federal privacy laws, and as a condition of treatment, audio or 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.
- ACKNOWLEDGEMENT: I have read and understand VEI’s Consent for Treatment and Financial Policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by VEI from time to time. A copy of the authorization will be considered as valid as the original.