F i n anc i a l P o l i c y
1. Your insurance policy is a contract between you and your insurance company. We file as a courtesy.
2. If you have an HMO or PPO insurance requiring a referral, you must have a completed form or an
authorization number with you at the time of your appointment. If you do not have the necessary
authorization information, you will be required to pay for your service at check-out.
3. All co-pays and deductibles must be paid the day of your appointment.
4. All charges are your responsibility whether your insurance company pays or not. Not all services are
a covered benefit in all contracts.
5. Fees are due at the time of your appointment. As a courtesy, we accept cash, checks, Discover,
Mastercard and Visa.
6. Contact lenses and/or optical goods must be paid at the time of delivery.
7. Accounts are considered past due 30 days after your insurance pays. We reserve the right to submit
accounts that are not paid within 90 days to a collection agency. All past due accounts are subject to
1/5% interest per month.
8. Medicare patients will be responsible for the $20.00 fee for the refraction (vision exam).
9. Fitting of contact lenses is a separate identifiable service from your eye exam. There is a minimum
fee of $25.00 for this service. A contact lens prescription cannot be determined without a fitting.
I hereby acknowledge that I have read, understand and agree to
the terms of this document relating to insurance coverage and
payment of my services.
Patient Name: _________________________________
Patient or Guardian’s Signature Date
Kathryn A. Hembree, M.D.
Susan M. Carney, M.D.
Audrey D. Blacklock, M.D., Ph.D.
Amy B. Steinman, O.D.
1200 Landmark Ave., Liberty, MO 64068 8660 N Green Hills Rd., Kansas City, MO 64154
P: 816.792.1900 F: 816.792.3548 www.NorthlandEyeSpecialists.com
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