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Dr. Michael D. Herreraadmin2017-07-06T01:14:31+00:00

Dr. Michael D. Herrera

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  • *VISION PLAN BENEFITS COVER “ROUTINE VISION” EXAMS. ANY MEDICAL HISTORY OR DIAGNOSIS THAT CAN AFFECT THE EYES WILL RESULT IN THE VISIT BEING BILLED TO YOUR MEDICAL INSURANCE AND MAY REQUIRE ADDITIONAL COPAY.*
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    *IF YOU ARE A CONTACT LENS WEARER ADDITIONAL FEES ARE CHARGED FOR CONTACT LENS SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING CONTACT LENS FEES, PLEASE ASK PRIOR TO YOUR EXAMINATION.*
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    I, the undersigned, assign all insurance or Medicare benefits, to Dr. Michael D. Herrera for any services furnished to me. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize any holder of medical information about me, to release such information to my insurance or the Health Care Financing Administration and its agents to determine the benefits payable for related services. I understand my signature requests that payments be made and authorizes release of medical information necessary to pay the claim. In the event of default in any amounts due, and if this account is placed in the hands of a collection agency, attorney for collections or legal action, I am to pay an additional charge equal to the cost of collection including collection agency, bank returned items charges, attorney fees and court cost incurred. In Insurance or Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the insurer or Medicare carrier as the full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination or the insurer or Medicare carrier.
  • YOUR INSURANCE OR MEDICARE MAY NOT PAY FOR ALL CHARGES, EVEN SOME CARE THAT YOU OR YOUR HEALTH CARE PROVIDER THINK IS MEDICALLY NECESSARY. I UNDERSTAND THAT MEDICARE WILL NOT PAY FOR THE PORTION OF MY EXAM THAT DETERMINES MY VISION CORRECTION AND I AM RESPONSIBLE FOR $35.00 PLUS TAX FOR THIS SERVICE. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY MEDICAL CHARGES INCURRED DURING MY VISION EXAM, AND THESE SERVICES WILL BE PERFORMED BASED ON THE DOCTOR’S PROFESSIONAL DISCRETION.
  • *Your Signature above indicates that this information has been made available to you*
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