Sports Vision Eval Plano

CONSTITUTIONAL

INTEGUMENTARY

NEUROLOGICAL

ENDOCRINE

Financial Responsibility Policy for
Charles Shidlofsky, O.D., P.A.
d/b/a Neuro-Vision Associates of North Texas

Your Health Plan Coverage

1. It is your responsibility to know if a referral is necessary for your visit
2. Co-payments are due at the time of the visit. We are considered “Specialty Co-payments”.
3. A valid, current insurance card must be presented at each office visit.
4. If the service is not a covered benefit, or if your health plans tells us you are not covered, payment in full for all services rendered are due on date of service .If your insurance subsequently makes payment, any over payments will be refunded to you.

Regarding Your Health Plan

1. Your insurance is a contract between you, your employer and the insurance company. We are not party to that contract. While we may have an agreement with many of the health plans to provide services, any questions regarding coverage must be resolved by you with the insurance company.
2. Not all services are a covered benefit in all contracts. Some health plans select certain services that they will not cover.
   
   By signing below, I acknowledge that I have read this information and understand completely.

• I have read or had explained to me that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and agree to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under said terms.
• I was given to opportunity to read that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practices and declined but wish to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under the tenns of that Neuro­Vision Associates of North Texas and its affiliated organizations privacy policies.
• I have read or had explained to me Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and do not wish to continue my care with Neuro-Vision Associates of North Texas and its affiliated organizations under said terms.
• The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as