Patient Forms

Payment is due on the day of service. All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.

Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided. 1 will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3 % attorney fee will be due from me. Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.

Our office participates with both medical and vision plans. in the event that your exam is billed medically and there is a remaining balance, we will first exhaust your vision plan benefits before transferring any balance to your account. I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.

HIPAA Acknowledgement Receipt: The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy. (HARD COPY AVAILABLE UPON REQUEST)