Billing and Financial Policy
PLEASE READ AND SIGN BELOW:
FINANCIAL POLICY: The following is a statement of our financial policy.
1. Patient Information: All patients must complete all of our Patient Information sheets and this form before
seeing the doctor. Unless previous arrangements have been made, all payments are due at the time of the
appointment. Payment can be made with cash, check, Visa, or Mastercard. We will only bill insurance carriers
with whom we participate (have a signed agreement with).
2. Participating Managed Care Insurance: You are responsible to supply our staff with your primary and/or
secondary insurance ID card(s) at the time of your appointment. If your insurance company requires a referral
from your primary doctor, you must also present this to our receptionist prior to being seen, as we cannot bill
your insurance without it. If you do not obtain a referral when your insurance requires one, you will be required
to pay for the visit in full. If your insurance requires a copay, it must be paid at the time of the appointment.
At times, your insurance carrier will deny payment for authorized services. If so, you may be asked to help
resolve these issues with your carrier. If you have a deductible, you will be responsible for paying the full
amount of the deductible as it pertains to your visit.
3. Non-Participating Insurances: If we do not participate with your insurance, the bill is your responsibility
and is due at the time of service. Payment can be made with cash, check, Visa, or Mastercard.
4. Medicare: We participate with Medicare. We will submit your claim to Medicare. The 20% difference
between what Medicare “allows” and what Medicare “pays” will be sent to your secondary insurance if you have
one, or to you. You are also responsible for the payment of your yearly deductible.
5.Returned checks: A Fee of $25.00 will be added to your bill if this occurs.
6. Cancellations: If you are unable to keep your scheduled appointment, 24 hours notice of cancellation is
required. Otherwise a $25 fee will be made for the time that was reserved for you.
7. Collections: Any outstanding balance for which the patient is responsible is due within 30 days. For every 30
days an account is overdue, a late fee of $15 will added to the account. For accounts that go unpaid past 90
days, late fees will cease and the balance will be sent immediately to collections with a 25% charge.
Thank you for your cooperation in understanding our financial policy. I have read the above Mack Eye Center
financial policy and I understand and agree to abide by its terms.
Notice of Privacy Practices & Office Policy
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
Uses and Disclosures:
Treatment. Your health information may be used by staff members or disclosed to other health care
professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing
treatment. For example, results of laboratory tests and procedures will be available in your medical record to
all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of
coverage such as an automobile insurer, or from credit card companies that you may use to pay for services.
For example, your health plan may request and receive information on dates of service, the services provided,
and the medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities
and management of Mack Eye Center. For example, information on the services you received may be used to
support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support
government audits and inspections, to facilitate law-enforcement investigations, and to comply with
government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by
law. For example, we are required to report certain communicable diseases to the state’s public health
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any
purpose other than those listed above requires your specific written authorization. If you change your mind
after authorizing a use or disclosure of your information you may submit a written revocation of the
authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure
of information that occurred before you notified us of your decision to revoke your authorization.
Additional Uses of Information:
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information that you may
find interesting on the treatment and management of your medical condition. We may also send you
information describing other health-related products and services that we believe may interest you.
You have certain rights under the federal privacy standards. These include:
The right to request restrictions on the use and disclosure of your protected health information.
The right to receive confidential communications concerning your medical condition and treatment.
The right to inspect and copy your protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom your protected health information has been disclosed.
The right to receive a printed copy of this notice.
Mack Eye Center Duties:
We are required by law to maintain the privacy of your protected health information and to provide you with
this notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices:
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes
in our policies and practices may be required by changes in federal and state laws and regulations. Upon
request, we will provide you with the most recently revised notice on any office visit. The revised policies and
practices will be applied to all protected health information we maintain.
Requests to Inspect Protected Health Information:
You may generally inspect or copy the protected health information that we maintain. As permitted by federal
regulation, we require that requests to inspect or copy protected health information be submitted in writing.
You may obtain a form to request access to your records by contacting the receptionist or Dr. Mack. Your
request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the
Payment is required at the TIME OF YOUR VISIT. We accept cash, check, debit, Mastercard, or Visa. If you have
insurance you MUST present your insurance card at the time of your visit. Please notify the office of any
address, phone number or insurance changes. Any co-payments are due at the TIME OF YOUR VISIT. There will
be a service charge of $25.00 on all returned checks.
**There will also be a $25.00 charge for all NO CALL/NO Show appointments that are not cancelled 24 hours in
advance of appointment time. Late fees will be applied to past due accounts over 90 days.
Prescriptions should be renewed Monday thru Friday. Twenty-four (24) hour advance notice is required for
phone-in/fax prescription renewals. Please do not call for renewal after office hours or on weekends. Renewals
of all triplicate prescriptions require periodic office visits to monitor your progress and prescription use.
Please allow up to five (5) working days for completion of your medical forms. Depending on the complexity of
the forms, we reserve the right to charge for the completion.
Due to the rising costs in operating our medical practice, there will be a $20.00 fee plus $1.00 per page charge
to copy and/or mail your medical records. Upon payment and receipt of a properly signed authorization, your
records will be transferred within ten 10 business days.
If you are allowing your lawyer or life insurance company to retrieve copies of your records, the fees stated
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a
letter outlining your concerns to:
Mack Eye Center
257 Monmouth Road, Suite 1B
Oakhurst, NJ 07755
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending
a letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
This notice is effective as of 12/1/2016.
Information To Be Used or Disclosed:
The information covered by this authorization includes (some or all of the fields listed):
Eye exam results, including photos and/or scans, Blood/Radiologic test results, Consultants reports,
Information on current or planned medical treatments
Purpose of Disclosure
Information listed above will be disclosed for general information purposes and/or medical decision making.
Information listed above will be used or disclosed by Dr. Mack.
*Persons To Whom Information May Be Disclosed: Please make sure you filled out the fields at the top of this
Expiration Date of Authorization
This authorization is effective indefinitely unless revoked or terminated by the patient or the patient’s personal
Right To Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Mack Eye Center. You
should contact the office to terminate this authorization.
Potential For Redisclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to
which it is sent. It may not be possible to ensure your right to the protection of the privacy of this information
once Mack Eye Center discloses it to another party.
Rights of the Individual
You may inspect or copy information used or disclosed under this authorization.
You may refuse to sign this authorization.
Effect of Refusing Authorization
If you refuse to sign this authorization, Mack Eye Center will not deny you any treatment except research related
treatment or treatment that you have requested for the purpose of disclosure to others.