1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to John L. Bonner Eye Clinic for services furnished me by John. L. Bonner Eye Clinic. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. John L. Bonner Eye Clinic accepts the charge determination for the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to John L. Bonner Eye Clinic, if possible or otherwise to me.

3. RELEASE OF INFORMATION: John L. Bonner Eye Clinic may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to John L. Bonner Eye Clinic for reimbursement for services rendered, and (2) any health care provider for continued patient care. Please see our Notice of Privacy Practices for information on your rights under the HIPAA Regulations, 45 CFR Parts 160 and 164. John L. Bonner Eye Clinic may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authorization may be used in place of the original.

4. INSURANCE COVERAGE: John L. Bonner Eye Clinic contracts with most of the major health plan payers; however, I acknowledge that it is my responsibility to confirm specific health plan coverage and benefit levels. Our business office is available for assistance at 218-326-3433. I understand that I am responsible to pay for any health care services for which my health plan denies coverage.

5. NON-COVERED SEVICES: I understand that John L. Bonner Eye Clinic contracts with health care plans that identify items and services which are “covered services.” Accordingly, the undersigned accepts full financial responsibility for all items or services, which are ultimately determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary of health care service plan furnishes to the patient; and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with John L. Bonner Eye Clinic to obtain necessary health care service plan authorizations. Payments for non-covered services are expected at time of service.

6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by John L. Bonner Eye Clinic, I will pay my account at the time service is rendered or will make financial agreements satisfactory to John L. Bonner Eye Clinic for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to John L. Bonner Eye Clinic. If copayments and/or deductibles are designed by my insurance company or health plan, I agree to pay them to John L. Bonner Eye Clinic. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.

7. EYE DROP ADMINISTRATION: I understand, as a patient, or parent/guardian of a minor child, that my eyes may be dilated as part of the exam. Dilation and other drops used during my visit can affect vision and function for a period of time. By signing below, permission is granted to dilate and give other drops.

We are pleased you have chosen John L. Bonner Eye Clinic for your eye care needs. To help answer some of your billing and insurance questions, we have compiled some information to guide you through the process.

MEDICARE:

If you have Medicare, our office will bill Medicare and/or your secondary insurances. You are responsible for the following:

• Any deductibles and co-pays
• 20% co-pay of the allowed charges
• Any non-covered services
• Services ordered by the physician that do not meet Medicare guidelines for medical necessity
• Routine eye examinations or refraction charges

MEDICAIDE (Minnesota Only)

If you have Medicaid, you are required to present a current Medicaid card at every visit. You are responsible for the following:

• All non-covered services
• A co-pay of $3.00 which is due at the time of service

HMO & PPO PLANS

If you have HMO or PPO coverage, you are required to obtain an insurance referral for most services. It is your responsibility to obtain all insurance referrals before services are rendered. You can do this by calling the referral department of the clinic listed on your insurance card. If you fail to obtain an insurance referral and services are denied, the balance will become your responsibility. Please call us at 218-326-3433 and we will be happy to assist you in obtaining this referral.

COMMERCIAL PLANS

If you have a commercial plan, we will bill your insurance company as a courtesy. If payment from your insurance company has not been received within 30 days, you are responsible for the balance in full. You are also responsible for the co-pay and/or any non-covered services. Co-pays are due at the day of service.

BILLING CYCLE

If your insurance information is verified at registration, you will not receive a bill until:

• Your insurance company has denied the claim
• Your insurance company has paid the claim, leaving a co-insurance, deductible or non-covered service.

OR

• Your insurance company has not responded to the claim

ROUTINE VISION PLANS:

Some employers have separate vision benefit plans specifically for routine eye exams called “carve out” plans. These plans are separate from your medical insurance coverage and are handled by a different company. We do NOT participate with these plans. These include, but are not limited to:

• VSP (Vision Service Plan)
• Cole Managed Vision
• EyeMed
• Amerisight
• Spectera

If you have this type of vision plan, you will be responsible for payment in full for your services. If you are scheduled for a routine vision exam, please review your vision benefits carefully. 

ROUTINE EXAMINATION AND REFRACTION CHARGES 

Benefit coverage for routine eye examinations and refraction charges vary by health plan and by employer. Specific benefit coverage can also change from year to year.

An examination is considered routine when performed for a patient who has no specific illness, symptom, complaint, or injury that needs to be treated or diagnosed.

A refraction is a test that is used to determine any optical defect present in the eye. A refraction is necessary

• To prescribe the best corrective lenses
• To determine the progression or diagnosis of certain ocular diseases
• To ascertain the basis for your visual complaints

You will want to check benefit coverage with your insurance carrier to determine if vision care is a covered service.

John L. Bonner Eye Clinic will submit this charge on your behalf to your insurance carrier for determination of benefit coverage. However, if you know this charge will not be paid by your insurance carrier, you may make payment on the date of service.

For questions regarding your account, call our Billing Department at:

218-326-3433