Financial Responsibility Form




Bannett Eye Centers, P.A. will be happy to submit an insurance claim form to your insurance for you for today’s visit. If we participate with your insurance, our billing office will receive an Explanation of Benefits telling us what the allowable amount of the services are, how much the insurance company is paying, how much we have to write off, and what you owe. You will receive this same Explanation of Benefits in the mail.

If we do not participate with your insurance, we will still be happy to submit a claim form to your insurance, however, you will be responsible for all charges incurred. Because we do not participate, we may or may not receive an Explanation of Benefits, and your insurance company may pay you instead of us. You should receive an Explanation of Benefits.

EVERY PLAN IS DIFFERENT. Please do not expect us to know the details of your plan. You are responsible to know that.


I ____________________understand I will be financially responsible for the following:

             (Print name here)

  1. All charges which my participating insurance company applied to my deductible, copay and coinsurance.
  2. All charges which are deemed “non-covered” by my plan.*
  3. All charges for which I should have gotten a referral, but did not.
  4. Routine eye care” exams that are not covered under my plan.**
  5. All charges, if I have a non-participating insurance company or no insurance at all.
  6. Not giving the office accurate and current insurance information. ***

 *Refractions are not covered by most insurance plans, including Medicare ( and Medicaid. A refraction is that part of the eye examination that determines whether you need prescription eyeglasses to improve your vision, or whether there has been a change in your glasses prescription since your last visit. When the technician asks you, “Which is better, one or two?,” that is the refraction part of your office visit. A change in your vision can be caused by many things, ranging from natural aging, including the development of cataracts, to more serious eye diseases. While a refraction is usually only needed once a year, sometimes it may be necessary more frequently, especially if a patient notices and complains about a change in his/her vision. The objective information obtained from a refraction is crucial to assisting the doctor in his/her assessment of the health of your eyes. IF YOU DO NOT WISH TO HAVE A REFRACTION, PLEASE ADVISE THE OPHTHALMIC TECHNICIAN WHO WORKS YOU UP. You will need to sign a waiver stating that, by refusing a refraction, you understand that you are taking away this crucial piece of information from the doctor, which may impact on your exam. You should also be aware that, without a refraction, the doctor will be unable to update your eyeglasses prescription. Our current fee for a refraction is $50.

**Many insurances, including Medicare, will only allow you to see an ophthalmologist if you have a medical diagnosis, not a “routine eye care” diagnosis. Examples of “routine eye care” diagnosis are myopia (near sightedness), hyperopia (far sightedness) and presbyopia (difficulty reading). You are required to know whether your plan covers “routine eye care” by an ophthalmologist.

 ***If you do not give us accurate and current insurance information, our claims will not be properly processed. Every insurance company has their own “timely filing” period – some as little as 90 days. If our claims are delayed because you give us the wrong information, you will be responsible for our bill.

                                                   Our Billing Policy

Payment is due at the time services are rendered. If there is a balance due on your account, we will send you a bill. We will send four bills before we send your account to our collections agency. If your account is turned over to a collection agency, you will also be responsible for their fee. Your signature below indicates you have read and understood the information provided in this statement, and agree to pay your bill in a timely manner.

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Latest comments

16.05 | 14:57

Thanks, Angel!!

16.05 | 14:56

Thanks Roe!!

16.05 | 14:55

Thanks Karen!!

16.05 | 14:54

Dr. Bannett operates at the Wills Surgery Center in Cherry Hill. We also do certain laser procedures in our office.

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