PAYMENT, FINANCIAL RESPONSIBILITY AND PHOTGRAPHIC
DISCLAIMER AND CONSENT

Payment Policy: Payment is due at the time professional services are rendered. For your convenience all major credit cards, personal checks and cash are accepted.

Insurance Claim filing: We accept MEDICARE, selected PPO; POS: AND COMMERCIAL insurance plans. PLEASE BE ADVISED, THERE ARE SOME CLINICAL AND SURGICAL PROCEDURES THAT YOUR INSURANCE WILL NOT COVER. THEREFORE BY SIGNING THIS DOCUMENT, YOU AGREE TO BE HELD FINANCIALLY RESPOSIBLE FOR SERVICES RENDERED ON OR BEFORE THE TIME OF SURGICAL OR CLINICAL SERVICE. The filing of your insurance claim is a courtesy to you and does not guarantee payment. The medical claim payment process can take up to forty-five days to complete, we ask for your patience while this process is taking place.

Surgical Predetermination Process: Predetermination takes place prior to surgery and requires that a letter of medical necessity, any photographs and /or testing be sent to your insurance company for review and possible approval. This process can take four to six weeks, and if surgery is approved, there is no guarantee of payment. Should you wish to proceed with an unapproved surgical procedure, you will be asked to sign the waiver in lieu of insurance claim filing, and we ask for payment in full. Ophthalmic Plastic Surgeons of Texas, LLC will not refund any private pay monies collected on an unapproved surgery. You may wish to file the claim on your own and agree to accept what your insurance company PAYS YOU, after the surgery has taken place.

(1) I understand that Dr. Longo/OPST/Billing Department Staff will make all reasonable efforts to collect payments due from any third party payors/insurance companies. In the event that the insurance company/third party payor refuses to pay for whatever reasons, I agree to be financially responsible for the remaining balance on my account.

Medical/Surgical Assignment of Benefits and Release of Medical Information Agreements: I request payment of my authorized insurance benefits be made payable to Ophthalmic Plastic Surgeons of Texas, P.A, on my behalf for unpaid medical and/or surgical procedures or future charges. I also authorize OPST and Dr. Longo to release medical information to my insurance company(ies) or agent(s), present or in the future, for claim purposes only.

(2) I understand Dr. Longo/OPST will make all necessary attempts to protect my privacy under HIPPA law. I may also ask for a copy of the privacy policy of Dr. Longo/OPST.