Thank you for selecting Plastic Eye Surgery Associates, PLLC (PESA) for your medical care. In order to prevent any misunderstanding over the responsibility of payment for medical and surgical services provided to our patients, we supply you with the following information: The patient, guarantor, or the person bringing the patient (if the patient is a minor), is responsible for payment of services provided at the time of the office visit, test or procedure. We accept cash, personal checks (NSF charge: $30), and credit cards (American Express, Discover, VISA, & MasterCard). In the case of divorced parents, the parent bringing the child to the office is responsible for payment at the time of service. A copy of the bill, which is furnished at each visit, contains all the information necessary for you to submit to your insurance carrier.
If a referral from your primary care physician is required by your insurance plan it is your responsibility to bring this referral with you and present it at the registration desk at the time of your visit. You will be asked for your insurance card and driver’s license at the registration desk for identification purposes.
PESA CONTRACTED INSURANCE COVERAGE
If you have coverage through an insurance company that has a contract with the doctor you are seeing, we require a copy of your insurance card and payment of your deductible or copayment at the time of service.
NON-PESA CONTRACTED INSURANCE COVERAGE
If you have coverage through an insurance company that does not have a contract with the doctor you are seeing we require a copy of your insurance card, and payment of your deductible or copayment at the time of service. We will file the claim as a service to you.
If you have Medicaid coverage, you must provide a current Medicaid card at the time of your visit. If the card is not available, you must either pay for the visit or reschedule the appointment. If within three months after the visit you receive a retroactive card that covers the date of the visit payment will be refunded after Medicaid has paid for your visit. You must pay for non-covered services at the time of your visit.
Office visits to a doctor are covered under Part B of the Medicare program. Medicare pays 80% of their allowable charges after you pay the annual deductible for the calendar year. You are fully responsible for any non-covered services. As a courtesy, if you have supplemental insurance, we will be glad to file this for you.
View it as a PDF document: Financial Policy