The doctors and staff at our office appreciate the confidence you have shown in choosing them to provide for your medical needs. We are devoted to providing you with the highest quality healthcare.
Patient Financial Responsibilities
· The patient (or patient’s guardian, if a minor) is responsible for the payment for his/her treatment and care.
· Patients are responsible for the payment of copays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of the service.
· It is the policy of Dr. Zubin Jiwani OD & Associates to collect copays/deductibles/allowable regardless if the patient has a Health Savings Account or Health Reimbursement Account.
· Patients may incur, and are responsible for the payment of the following additional charges:
o A $25 fee for all returned checks
o A $25 for No show or missed appointments.
The following are the patient’s responsibility:
1. Pre-Authorization: It is the patient’s responsibility to know when authorization/referrals are required for services rendered. The patient must contact their Primary Care Physician for any referrals and contact their insurance company for Pre-Authorization. We will be happy to assist if your insurance has any requests.
2. Patients must bring their insurance card and driver license to each visit.
3. If patient fails to provide their insurance information before the date of service may result in delayed verification of benefits. If insurance information is not provided and the services are rendered, the patient will be responsible for the full cost of service.
4. Determine if doctor(s) are in-network providers prior to first visit.
5. Pay for any allowed amounts not covered by insurance
6. If you do not have insurance benefits, please contact the Billing Department to set up payment arrangements.
1. Since all prescription glasses are customized according to your eye measurements and your prescription, all prescription glasses/ sunglasses/ eyewear/ contact lenses are sold under no return and no refund policy.
2. Payment is due in full for all types of rx glasses and contact lens orders unless authorized by the office manager or the doctor.
3. Follow up for eyeglass recheck or contact lens rechecks are offered at no charge until 30 days after the pickup date. Any services or recheck services after 30 days will be patient’s responsibility at $70 per visit.
4. Patient is responsible to inform the office through email admin@myeyecareexperts or phone 713-340-0000 if there in any issue with their glasses or contact lenses as soon as possible so it can be rectified within the warranty period.
5. Any new prescription eyeglasses and contact lenses sometimes takes some time to adjust to. We recommend patients to give at least 2 (two) weeks of adaptation time to the new eyewear/ contacts.
6. For Progressive additional lenses, in case of a non-adapt, we are happy to replace lenses in the same frame, with a flat top bifocal or distance or reading single vision glasses at no cost.
7. In case of a progressive non-adapt or prescription non-adapt, our office will work with you to fix the problem with the glasses and or prescription until it is fixed.
8. For contact lens trials, we only provide patient with 2 weeks supply of trial lenses, unless there is a problem with the Rx and the lenses have to be changed within the trial period. Additional trials can be provided to the patient at additional cost.
9. New contact lens patients will be charged an extra fee for contact lens training, insertion and removal which is not covered by insurance. This fee can be anywhere from $40 to $60 depending on the duration of training provided. This is a separate service fee than contact lens fitting fee.
10. For Spectera vision plan members, if your contact lenses or the prescription of your contact lenses does not fall under the formulary list of spectera, contact lens fitting will be out of pocket.
Payment Policy and Refund policy for dry eye procedures:
Scheduling a procedure requires the coordination of many different resources. This takes time to handle properly so that the patient will enjoy a quality experience. You acknowledge and agree that upon execution of this Invoice of procedure Fees (the “Agreement”), Dr. Zubin Jiwani OD & Associates PLLC d/b/a EYECARE EXPERTS will incur certain costs and expenses in order to schedule and prepare for your procedure(s). As such, you are required to pay to Eyecare Experts a one-time NONREFUNDABLE deposit in the amount of $1,000.00 (the “Deposit”) concurrently with the execution of this Agreement. You agree and acknowledge that the Deposit SHALL IN NO EVENT BE REFUNDABLE, NO MATTER THE CIRCUMSTANCES. Specifically, failure to obtain medical clearance for any reason shall not entitle you to a refund.
Your payment of the Deposit is valid for one (1) year. Thereafter, you will be charged an additional amount to proceed with this, or any other, procedure(s) with Eyecare Experts. You also understand that should your procedure(s) not occur within one (1) year from the execution date of this Agreement, the prices quoted herein may be subject to change.
Procedure fee ONLY includes the following: pre- and post-procedure visits; and the mentioned or advised procedure(s). You must obtain any and all blood work, CXRs, mammograms, medical clearance, prescriptions, and other ancillary services at your own expense.
You also agree and acknowledge the total Amount Due shall be paid in full prior to the date of your procedure(s). Your failure to remit the total Amount Due by such date will result in the cancellation of your procedure(s).
Any rescheduling or cancellation fees are patient's responsibility. If someone other than the patient makes any payment(s) towards the procedure(s), then that payor must also sign this Agreement.
Just like any other medical procedure, Optilight, Tear Care, Ilux (Dry eye treatment) RESULTS ARE NOT GUARANTEED. To be clear, your obligation to pay the total Amount Due, as well as any other obligations hereunder, are operative regardless of the outcome of any procedure(s). Your payment is for the services provided hereunder, not the results. In the event that you are not satisfied with the results of your procedure(s), your treatment, or you wish to discuss any payment terms, then you should contact Eyecare Experts (713)-340-0000.
In the event that you cancel your procedure(s) (for any reason whatsoever) you agree and understand that the following applies:
(a) 30 days’ notice.
If you cancel your procedure(s), for any reason whatsoever, and such cancellation occurs thirty (30) or more days before the scheduled procedure(s) (or at any time if no procedure has been scheduled), then you shall be entitled to the Amount Due less the Deposit. If the Amount Due was not paid in full, then the refund shall consist of the amount then-paid to Eyecare Experts, less the Deposit.
(b) 15-29 days’ notice.
If you cancel your procedure(s), for any reason whatsoever, and such cancellation occurs less than thirty (30) days but no fewer than fifteen (15) days before the scheduled procedure(s), then you shall be entitled to a refund of fifty percent (50%) of the Amount Due less the Deposit. If the Amount Due was not paid in full, then the refund will consist of the amount then-paid to Eyecare Experts, less the Deposit, and less the Post-procedure Cancellation Fee, if applicable. In addition, you understand and agree that your refund may also be reduced by any costs incurred from third-party providers in connection with your procedure(s), such as, but not limited to, the costs of treatment kits ordered.
(c) 0-14 days’ notice.
If you cancel your procedure(s), for any reason whatsoever, and cancellation occurs less than fifteen (15) days before the scheduled procedure(s), then you agree and acknowledge that you WILL NOT BE ENTITLED TO ANY REFUND WHATSOEVER.
You may choose to reschedule your procedure(s) (a “Rescheduled Procedure”), in which case you will be assessed an additional $1000.00 rescheduling fee (the “Rescheduling Fee”) in addition to the Amount Due hereunder. You agree and understand that should you cancel any Rescheduled Procedure; you will also be assessed a $1,000.00 cancellation fee for each canceled Rescheduled Procedure.
Refunds and Claims
We are taking extreme measures in order to avoid disputes, claims and chargebacks. We have adopted a 0 Tolerance policy in order to help the community in these uncertain times. If you would like to receive a refund for charges or change your mind about having a procedure done, please e-mail our accounting department at firstname.lastname@example.org .