Lakeville Family Eye Care, P.A. will be happy to file your insurance claim on your behalf. However, any benefits quoted by us or relayed from your insurance carrier(s) are only an estimation of benefits, not a guarantee of coverage. A final determination cannot be made until a claim is processed by your insurance carrier(s). While we are willing to check for you, knowing your insurance benefits and restrictions are ultimately your responsibility. If your insurance company or policy requires a referral or prior authorization, it is your responsibility to make sure that this is obtained before services are provided. If the services provided are not covered by your plan or are not of the contractual obligation with that carrier, the bill remains your responsibility.
- This waiver shall stay in effect from the date shown below going forward until rescinded by Lakeville Family Eye Care That I was Informed and offered Lakeville Family Eye Care’s Notice of Privacy Practices. You can request a copy of our HIPPA policy by emailing Lisa Blacksten, Security officer at lfec.lisa@gmail.com.
- I authorize Lakeville Family Eye Care to release or request my medical records to or from any previous providers.
- I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services.
Patients are asked to confirm their appointments at least 24 hours in advance by directly contacting our office or by responding to our confirmation contact. Failure to keep your appointment may result in a charge for the time reserved, as this time could be given to another patient in need. It is required to confirm an appointment at least 24 hours in advance. If a 24-hour notice is not given, a cancellation fee of $50 may apply.
There will be a minimum fee of $30 for any checks returned as Non-Sufficient Funds (NSF).
Patient balances that go unpaid for 90 or more days may be referred to a collection company or attorney. In the event this occurs, you will be liable for the collection cost. Further, in the event any unpaid account balance is referred to an attorney for collection, you may also be responsible for all costs and reasonable attorney’s fees incurred in connection therewith.
I understand and agree to be responsible for payment of all services rendered on my behalf or my dependents’ behalf.
