Financial Policy and Patient Agreement

Financial Policy and Patient Agreement

The following is the financial policy and disclosure information for Bettner Vision. Please read and sign prior to treatment.

Payment is due at the time of service. This includes co-payments, co-insurance, or deductible payments. Delinquent payment at the time of service will be billed to you and is considered past due if not received within 30 days from the date of service. You will also be responsible for any charges your insurance company applies toward your deductible and will be billed accordingly.

The patient accepts financial responsibility for all goods and services rendered unless Bettner Vision has an agreement with the patient’s insurance carrier for alternative payments. As a courtesy to patients, the practice will file insurance claims with all standard insurance carriers.
Insurance information includes:
1. – Any necessary referrals for primary and secondary insurance coverage.
2. – All identification documents.
The Patient agrees that if their insurance company denies coverage for any reason, or if payment is not received from the insurance carrier within 45 days as designated by Colorado law, then the patient is responsible for payment in full.

By signing this agreement, the patient authorizes the exchange of information relating to care and claims with the patient’s insurance company(s), and allows insurance payments be made directly to Bettner Vision for services provided under the patient’s insurance agreement.

The patient understands that an account balance 60 days or more delinquent is subject to a finance charge of 1.5% per month (18% APR). In the event that an account is overdue and turned over to our collection agency, the patient or responsible party is responsible for any collection fees charged to Bettner Vision. Fees include any finance charges, attorney fees, court costs, and any other administrative expenses.

Bettner Vision has contracted its insurance billing with Emdeon Business Services LLC. It will be necessary to provide this billing service with certain information in order to file some select insurance claims. Emdeon Business Services LLC is HIPPA compliant and will adhere to the Client Confidentiality as outlined in the Notice of Privacy Practices.

  • Patient Agreement: I have read and understand the Financial Policy and disclosure information and agree to the terms stated above. (Typing your name and date of birth means you accept and understand the Financial Policy and Patient Agreement)