Patient Financial Responsibility


Eyecare and Eyewear’s Billing Policies & Procedures

Major Medical Insurance plans differentiate between medical benefits and well vision / routine benefits.  Some Major Medical Plans do offer benefits for well vision / routine eye exams. It is important that you know if you have benefits for both types of visits.  It is also important to check if you have seperate copays and deductibles for both the office visits and medical testing.

We make great efforts to obtain your benefits prior to your scheduled office visit but the information may not be as detailed as we need.  It is unfortunate that insurance companies state “a quote of benefits does not guarantee payment”.  If a claim is denied for a particular service due to a deductible not met, and /or copays not covered, the patient is responsible for any and all balances.  A statement will be sent to the responsible party explaining the reason for the non covered service according to the information provided to us by your medical carrier.

ECEW, as a service:

1.  Will file claims to your insurance provider for services rendered.

2.  Will  re-file claims denied due to incorrect coding and/or billing errors.

3.  Will not refile claims due to denied coverage, deductibles not met, copays not met.

4.  Will not alter the original diagnosis and refile claims to see if the medical carrier will pay the claim.

5. We do not file insurance unless it has been validated prior to your visit.

If the Doctors are not providers on your medical plan

You are responsible at the time of your visit for the full amount for all services and materials provided.
ECEW will provide a receipt that contains all cpt codes / procedures and diagnosis codes that you will need to file to your medical carrier.

For our patients without vision benefits or health insurance

1. We offer 30% off of a well vision exam.
2. We offer discounts on eyewear.

Patient Acknowledgement and Acceptance of Responsibility

I accept the policies as outlined above and understand that I am ultimately responsible for paying all balances on my account and on my dependent’s account regardless of my insurance benefits.  I understand that ECEW will file my claim in a correct and timely manner and will re-file on claims denied for incorrect coding or billing errors. Signature:  ________________________________

In the event ECEW files insurance on my behalf, I authorize the release of medical information necessary to process claims.  I also authorize payment of medical benefits to ECEW for services provided.  A photocopy of this assignment is as valid as original.

I acknowledge I was offered a copy of the HIPPA Compliance Form.

Download/view Patient Financial Responsibility form PDF

Tel 972-307-5000 | Email ecew@ecew.com | Fax 972-307-7717
3012 E. Hebron Parkway. Suite 100, Carrollton, TX 75010-4461

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