We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your responsibility.

FINANCIAL POLICY

· The Patient is responsible for all fees. Full payment is due at time of service unless other arrangements have been made in advance.

· We will accept assignment on your insurance benefits and will expedite insurance claim processing to insure prompt payment and accurate reimbursement.

· Deductibles and co-payments are due at time of service on all insurance plans.

· Patients covered under non-participating insurances must pay 100% of any unpaid deductible or out of pocket expenses under the terms of their contract.

· If insurance payment is not received within 60 days of your date of service, the Patient becomes responsible for the outstanding balance.

· Late charges of 2% will be assessed against the outstanding balance for any amount owed over 60 days. This charge will be assessed monthly until the account is paid in full.

· Delinquent unpaid balances including previous adjustments will be forwarded to a collection agency or attorney.

I have read and understand this financial policy and agree to its terms. I agree to pay for services rendered. I agree to pay attorney fees and collection costs in the event it becomes necessary to retain such services for collection of my account.

I authorize the release of medical information and records concerning my treatment to Medicare, Medigap and/or other insurance companies and assign my claim for medical benefits to the extent permitted under applicable law or insurance agreements. I release all legal responsibility or liability that may arise from the above authorizations and agreements:

Patient Signature Date

Responsible Party Date

I authorize the physicians and staff of Athens Retina Center to dilate, test and examine my eyes to the extent necessary to determine the underlying cause of my visual difficulties and to offer possible treatment options available to me.

Patient Date

Guardian Date