We are committed to providing you with the best possible care. If you have medical / vision insurance we are eager to help you receive your maximum allowable benefit. It is your responsibility to understand your insurance benefits (some insurance companies that we are contracted with have added a vision plan that is separate from the major medical and we may not be providers). If we are not contracted with your insurance we may file a claim as a courtesy. All unpaid balances are patient responsibility. If you would like us to bill your insurance you must provide a copy of the insurance card.

If you are not contracted with your insurance and do not submit a claim, we will offer you a cash discount. We would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.
I understand that I am responsible for payment of any charges not covered by my insurance.
I authorize payment of healthcare benefits to this clinic.
I also authorize release of any medical records necessary to process any claims.

Our intent is to provide you with the highest level of service and care. Part of this service is offering an explanation of our financial policies.

1. It is important for patients to be informed consumers who understand the specifications of their insurance policies. Your health insurance policy is a contract between you and the insurance company.

2. Each individual patient is responsible for all payment obligations arising out of treatment and care and guarantees payment for these services. You are responsible for deductibles, co-payments, co-insurance or any other patient responsibility indicated by your insurance carrier.

3. Our office may check eligibility, however you will be held responsible for knowing the extent and specifics of your specific insurance policy. Please note that some insurance companies contract with third party carriers for routine vision coverage, and Dr. Green may not be contracted with those vision carriers. Always verify with your insurance company that Dr. Green is a preferred provider in order to get the best benefits possible.

4. Your insurance company makes a final determination of benefits when they receive our billings. Any statements made by our staff regarding your coverage are made in good faith but may not be completely accurate even if we have your insurance information to verify coverage.

5. If there are any problems between you and your insurance company, you may file a grievance directly with your insurance company.

6. If payment has not been received within four months on an outstanding balance, the account may be sent to a third party collection agency. NSF checks or rejected credit card payments will be charged a service fee of $30.00 per occurrence.

7. Please feel free to ask any financial questions you may have. Again, our intent is to provide you with the highest level of service and care.

By signing below, I acknowledge that I understand the policies as contained herein.

I acknowledge that I have had the opportunity to review the updated Notice of Privacy Practices and Patient Consent form of Bellingham Family Eye Clinic PS. effective date 07/11/2019. I may request a copy if I desire one for my own records.