Required Agreement to Provisions
The following is a statement of our Financial Policy that we require you to read, understand, and sign prior to any treatment.

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Patient Information Form
All patients must complete our Patient Information form before seeing the doctor. We verify your insurance information at each visit, so please bring your insurance card(s) with you to every appointment. In order for us to bill your insurance company, we need complete, current, and accurate information, including a copy of your card.

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No Insurance
If you currently have no insurance, all services provided are to be paid in full at the time of service.

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Co-pays, Deductibles, and Co-Insurance
All co-payments, deductibles, and co-insurance are due at the time of check-in. All Medicare patients will be required to pay their yearly deductible and the 20% coinsurance, based upon the current Medicare Fee Schedule, at the time of services unless proof of secondary policy is evident.

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Methods of Payment
Payments may be made with cash, personal check, VISA, MasterCard, Discover or American Express.

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Contracted Health Service Plans
Julie Foreman M.D. maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office. Glaucoma Consultants of Texas has no contract expressed or implied, with any plan that does not appear on the list. It is your obligation to pay the full charges of all services rendered by Julie Foreman M.D. if you belong to a plan that does not appear on the list of accepted insurances.

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Covered Services
Julie Foreman M.D.contracts with health care service plan (i.e., HMOs, PPOs) related only to items and services which are "covered" by the health care service plans. Accordingly, it is your full financial responsibility for all items or services which are 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 the health care service plan furnishes to the patient, and treatment or tests not authorized by the health care service plan. The patient or guarantor agrees to cooperate with Dr. Julie Foreman M.D.  to obtain necessary health care service plan authorizations.

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Delinquent Accounts and Collections
In return for the services provided by Julie Foreman M.D., you are required to pay the account at the time service is rendered or make financial arrangements satisfactory to Glaucoma Consultants of Texas for payment. If an account is sent to an attorney for collection, it is your responsibility to pay collection expenses and reasonable attorney’s fees as established by the court. If your account is delinquent, it will 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 Glaucoma Consultants of Texas. If co-payments and/or deductibles are designated by your insurance company or health plan, you agree to pay them to Julie Foreman M.D.

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Balances Due After Insurance
If the Clinic is a participating provider with your PPO or another insurance plan, we file charges to your insurance carrier. After the insurance company responds and if there is a balance due from the patient, you will receive a statement showing the charges, any payments, and the balance due. Although we have filed the charges to your insurance company, please remember that you are responsible for the account balance. Interest at the maximum allowed by law will be charged on all balances after 30 days.

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No-Show Appointments
There is a fee for no-show appointments and cancellations made less than 24 hours in advance of the appointment. The fees are $20 for an office visit, $50 for a laser appointment and $250 for a surgical appointment.

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Failure to Meet Financial Obligations
All account balances are due in full within 14 days of the billing date. Failure to meet your financial obligations may result in a collection action for your account balance. This may include the account being turned over to a collection agency, reported to a credit bureau, a claim filed for a judgment in small claims court. Once the account is placed in the collection status, your future services at the Dr. Julie Foreman M.D. will be suspended. The outstanding balance must be paid in full before you can be seen again in the clinic. Your account will then be on cash, credit card, or money order basis only. All attorney fees, court costs, and other expenses that relate to collecting your account will be added to your outstanding balance.

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All outstanding patient account balances must be paid in full before your next visit or your appointment will be rescheduled.

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Overpayment and Refunds
If an overpayment is made by you on the account, a refund will normally be issued if there are no other outstanding debts on your account or other account or other accounts containing the same guarantor or financially responsible party. It is your responsibility to inform us of any change in address, phone, employment or insurance.

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Returned Checks
There will be a $25 charge for all returned checks. If the check is forwarded to the District Attorney’s office for non-payment collection, additional charges will be the patient’s responsibility. Your account status following a returned check will be on a cash, credit card or money order basis only.

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Refusal to Pay
It is our obligation under many of the managed care contracts to report patients who repeatedly refuse to pay co-pays and deductibles at the time of service or who repeatedly "no-show" for appointments. Your healthcare benefits could be lost due to noncompliance.

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Divorce Issues
Dr. Julie Foreman M.D. will not become involved with any divorce issues. The adult accompanying a minor and the parents (guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized for payment by Visa/MasterCard/Discover, American Express, cash or check at time of service. The guarantor will be responsible for any balance on the account. Unresolved accounts will result in the account being sent to collections, regardless of who is responsible for the balance due.

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Third-Party Liability Insurance
Dr. Julie Foreman M.D. does not bill third parties such as attorneys or automobile insurance for liability services. Dr. Julie Foreman M.D. will provide any documentation to the patient to submit to a third party for reimbursement. Medical records requested by the third party are to be paid in advance of release.

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The foregoing financial policies are provided for your convenience. As a patient of Dr. Julie Foreman M.D., you must agree to these terms by signing and submitting an official paper copy of our financial policy, available from our Forms for New Patients page.

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If you have any suggestions or comments to improve our practice, your care, or our web site, please feel free to contact us.