PATIENT NOTICE OF OFFICE POLICIES 

Dr. Ly Nguyen and the staff of EYE FLORIDA & dba RejuveRx MedSpa are here to serve the eye needs of every patient.  We ask for your cooperation in adhering to the following Office Policies in order to better serve you and others like you. 

1.  PAYMENTS & PATIENT FINANCIAL RESPONSIBILITY 

I understand that I am financially responsible for all charges not covered by this assignment, including any insurance or co-payment, or for any charges, which the insurance carrier declines to pay.  If you need to make special payment arrangements, please discuss this with our office staff during the visit. Cash, Visa and MasterCard are accepted.  No personal checks will be accepted on NEW PATIENT.  I authorize and request my insurance company to pay directly to the doctor, or ophthalmic group, insurance benefits otherwise payable to me.  I understand that if for any reason my insurance company does not pay my bill within 90 days I will be fully responsible for payment.  Any returned checks will incur a $30.00 minimum returned check fee.  In the event the account becomes delinquent and is turned over to a collections agency, there will be a $50.00 fee for each account and that I am responsible for any collection, court, or attorney fees.  I also acknowledge that it is my responsibility to fully understand the rules and regulations of my insurance company.  

2.  NO SHOW/LATE CANCELLATIONS 

If an appointment is missed or not cancelled with 24 hours prior notice to the scheduled time, a fee of $30.00 will be charged since that time slot cannot be filled by another person.  All “no-show” or “late cancellation” fees are to be paid in full on or before the next visit. Insurance will not reimburse the patient for this charge, nor will Dr. Ly Nguyen/St. Cloud Eye Center INC bill the insurance for it. Our office staff makes appointment confirmation by phone as courtesy to our patient. Nevertheless, it is the patient’s responsibility to remember his/her appointment date and time.  

3. DILATION OF EYES 

In order to perform a thorough eye examination, it may be necessary to put drops in your eyes which will dilate them.  Dilation means that the pupils will become enlarged for a period of time letting in more light and potentially blurring vision particularly at near.  A few patients have experienced concern regarding their ability to function after dilation.  It has been our experience that the near vision is affected far more than the distance and that most individuals are able to “get around” although some caution is necessary in the presence of any decreased vision.  Some patients express concern about driving after dilation.  We encourage patients who have this concern to arrange for a driver when coming for an exam.  Please note that dilation is necessary in order to perform certain diagnostic testing and to give the doctor a full and enlarged view of the retina, or the back of the eye.  This is vital in evaluating and diagnosing the effects of many eye conditions including, but not limited to, cataracts, retinal diseases, and glaucoma.  If you have further concern regarding this please do not hesitate to let us know. 

4. REFRACTION 

Refraction is a measurement of the lens power necessary to prescribe glasses or other corrective lenses.  Most medical insurance plans, including Medicare, do not cover routine refractions examination (when no medical eye problem is known or suspected). The Health Care Administration/Medicare allows that we charge separately for that portion of the examination since it is a NON-COVERED SERVICES.  If you are interested in your prescription from our practice, then a nominal fee $35.00 will be due at the time of service. 

As of January 4th, 2021

There are two parts to your MEDICAL EYE examination, which are billed separately.

The first charge includes the fee for the doctor to evaluate the health of your eyes. This charge is billable to your medical insurance company, and also to Medicare.

The second (vision) portion of your exam is called a “refraction,” which is a test performed to determine the best corrective lenses to be prescribed for each eye.

Although a refraction (CPT 92015) is a very important vision test, it is considered a non-medical procedure. Medicare and most medical insurance plans do not pay for this service, the fee of which is now $35.00.

We request that payment for this service be made prior to getting your test (refraction) to update your glasses prescription. Thank you.

5. MEDICAL RECORD RELEASE 

Should you need copies of your records, please note the following in accordance with Florida Statute:  For copies of chart pages, a minimum of ten (10) working days and not more than thirty (30) is required to process your request.  A completed and signed record release must be done before any records are released.  If records are not being directly released to another physician’s office, there will be a fee of $1.00 per page for the first 25 pages and 0.25 cents per page after that, payable prior to release of your copies.  Reproduction of photographic materials will require additional time over and above ten (10) days.  Any reproduction of photographic materials will be billed to you at the cost of reproduction, payable prior to release.  

6. REFERRALS 

Please allow seven working days to coordinate referrals to other providers. 

7. REFILLS & PRESCRIPTIONS 

Please allow three working days for the coordination of refills and prescriptions with the pharmacy.  Always contact your pharmacist first when refilling a prescription.  The pharmacy will contact us for authorization if necessary.  If you require a “stat-same day” refill for a written prescription, there will be a $10.00 fee. 

8. DRIVER’S LICENSE FORMS 

We will be glad to fill out driver’s license forms at the time of your exam at no charge.  If the request for completion is not done at the time of your exam, then please allow five (5) working days.  Same day form completions (not at time of exam) will be charged $10.00 fee. 

9. AFTER HOURS AND EMERGENCIES 

In the event of an emergency situation, call 911 or go to the nearest Emergency Room.  If you have an urgent concern that you need to discuss with the physician, please call our office to schedule your appointment. All phone message left in the voicemail will be returned within 24 hours by the office Monday – Friday. 

YOUR PRIVACY  

Your medical records are strictly private.  No information will be given to others without your written permission, except as required by law.  Please see HIPAA notice for further details.