Patient Fees and Payment Policies Patient Fees and Payment Policies A. PAYMENT Payment will be collected at time of service Checks denied for lack of funds will incur a fee of $35.00 All balances must be paid within 30 days of the invoice date. We will either mail or text your outstanding invoice. Please give us a current address and phone number if we need to contact you. An administrative fee of $40.00 will be added to any unpaid balance that is over 30 days past invoice. Patient and/or Patient parent/guardian will be responsible for collection fees if account balance is turned over for collections. In some cases, the non-payment will be sent to a small claims court. We require 24 hours notice, received during normal business hours, for any patients to cancel or change an appointment. If you miss an appointment, you may be charged a $50 no show fee. We reserve the right to make changes to our fees and/or policies without advance notice. B. INSURANCE You are responsible for your copay/coinsurance at the time of service. Stephanie Cortes OD PA staff will submit, on your behalf, to your insurance company for reimbursement for services. You are responsible for all remaining deductible and coinsurance amounts. C. CONTACT LENS EXAMS The contact lens fitting includes trial lenses, corneal topography, and corneal assessment to properly fit your contact lenses. All fees are due at the time of service and they are non-refundable. You are responsible to return for your follow up appointment as determined by the doctor. If you don’t return for your follow up within 6 months of your exam, then you will be charged for a new contact lens exam. Contact Lens application and removal training: The fees for Contact Lens Training are $20 each session. Consent(Required) I hereby state that I have read and will abide by the Patient fees and Payment policies as advised on this document. I hereby assign and authorize payment directly to the providers at the office of Stephanie Cortes OD PA, the medical/vision benefits to which I am entitled under my insurance policy(s). I understand that I am financially responsible for charges not covered by this assignment. By receiving a service from Stephanie Cortes OD PA I am agreeing to pay for that service even if my insurance company denies payment. If I am not using insurance, I am responsible for all charges to this office.Patient Name(Required) First Last Patient / Representative / Parent Signature(Required)HiddenDate MM slash DD slash YYYY Overdue balances will incur an administrative fee of $40 added to any unpaid balance. Patient and/or Patient Guardian will be responsible for collection fees, if account balance is turned over for collections.CAPTCHA