| Financial Policy Thank you for choosing us as your health care provider! We are committed to provide the highest quality care and treatment for you. Please understand that payment of your bill is considered a part of your partnership in treatment. To read and agree to this Financial Policy Statement is required. All patients must complete the information and insurance forms before being seen. Full payment for services and/or co-insurance payment are due at the time of service. We accept cash, checks, VISA, MASTERCARD, DISCOVER or AMERICAN EXPRESS cards. For extenuating circumstances, and only with prior approval, other viable payment arrangements can be made as an alternative payment option. Insurance
We may accept assignment of insurance benefits if we are a participating provider. Any remaining balance is your responsibility. In order for us to bill your insurance company, you must give us current and correct insurance information. Your insurance policy is a contract between you and your insurance company only. Dr. Wun is not party to that contract. Please be aware that some, and perhaps all of the services we provide may be non-covered services and may not be considered reasonable and/or necessary under your health insurance policy even though we do. If we are a participating provider, all co-pays are due prior to treatment. If your insurance company does not pay all amounts due, you are still obligated and responsible to pay full amount charged. Since there are a multitude of policies, you are ultimately responsible for knowing and determining your insurance company's eligibility criteria, coverage amounts and deductibles, and compelling your insurance company to pay. We will bill one insurance company one time as courtesy, thereafter additional fees will apply if rebilling is required, or your insurance company requires additional information. Follow up of your insurance claim is your responsibility. Dr. Wun is committed to providing the best treatment for our patients. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates reasonableness and necessity. Privacy
Because new Federal and Insurance regulations govern how patient confidentiality is protected, we require specific written and signed consents and/or authorizations from you before we can communicate any patient information to third parties. After we receive a written request from you, all information releases will be in writing to you alone (see the "Notice of Privacy Practices" HIPAA regulations). Your Responsibility
By proceeding to enter and submit information to Dr. Wun from this website, you declare your responsibility for, and authorize treatment of the persons named herein. You agree to pay all fees and charges for such treatment. We must emphasize that our primary mission is to deliver medical care - not financial advice. Our relation therefore is solely with you, neither your insurance company nor former spouse. Further, the person being seen by the doctor (the patient), or, if the patient is a minor, then that adult person bringing in the child, is ultimately responsible for all charges for professional services rendered and/or materials used to care for that patient. The parent or guardian bringing the minor to this office is responsible for full payment. For unaccompanied minors, non-emergency treatment cannot be delivered unless written consent for treatment has been given and charges have been pre-authorized to a VISA, MASTERCARD, DISCOVER or AMERICAN EXPRESS card, or payment of cash or check at the time service is made. Missed Appointments
Please help us to serve you by keeping scheduled appointments. If you will be unable to keep your scheduled appointment, you must cancel it on the preceding day. If an appointment is missed and not cancelled by the preceding day, that appointment is lost and no one benefits. Medical Records Release and Statement of Understanding
By proceeding to submit any informational or contractual information from this website you declare that you have read and agree to the terms and conditions set forth above. You further agree to pay all fees and charges for treatment and materials the day services are rendered. You certify that your personal history and personal information are correct and you consent to the release of medical information to third party payers. Your Rights as a Patient
You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. -You have the right to receive confidential communications regarding your protected health information. -You have the right to inspect and copy your protected health information. -You have the right to amend your protected health information. -You have the right to receive an account of disclosures of your protected health information. -You have the right to a paper copy of this notice of privacy practices. Legal Requirements
Dr. Wun's Office is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this site, or are available within our office. Although we have gone to great lengths and expense to protect any information entered and submitted by you, or an agent or representative, to, and through this website, we cannot guarantee against any security breech that may include, but not be limited to any information that you volunteer. Contact Information
For further information about Silicon Valley Optometry Center, please contact Dr. Wun at the following address or phone number: Dr. Wun – 10525 S. DeAnza Blvd. Suite 190, Cupertino, CA 95014 Tel: (408) 725-1900 Fax:(408) 725-1989 |
