Justin A. Saunders, MD Plastic & Reconstructive Surgery of Eyelids, Tear Ducts and Orbit

Doctors Park, Suite 101 | 1517 Nicholasville Road Lexington, KY 40503 | (859) 277-4403

Financial Policy

Thank you for choosing Saunders Oculoplastic Surgery, PSC for your treatment. The purpose of this form is to help our patients understand about medical insurance, eligibility, coverage and benefits.

  • - We render our services on the basis that your insurance company may or may not pay for treatment.
  • - Authorizations and eligibility verification of coverage are obtained by our staff. However, all insurance companies state that authorizations and eligibility verification of coverage are NOT a guarantee of coverage or payment. Actual benefits are determined by your insurance company after a claim is received.
  • - Patients are responsible for knowing and understanding their own insurance policy including copays, co-insurance, deductibles and eligibility of coverage.
  • - Patients are responsible for copay, co-insurance, deductibles and non-covered/non-authorized services at the time of service. Surgery procedure copay, co-insurance and deductibles are due one week prior to service.
  • - We will file a claim with your insurance. However, any un-paid portion is the responsibility of the patient. Delinquent accounts are subject to late charges.
  • - I agree to pay all costs of collection including atotrney fees, collection fees, and contingent fees to collection agencies up to 40%. Such contingency fees will be added and collected by the collection agency immediately upon referral of my account to the collection agency.
  • - The fee for a returned check is $50.00
  • - Kindly give at least a 24 hour notice of cancellation or rescheduling an appointment so we may offer that time to another. No notice will be subject to $25.00 fee.
  • - Patients must present their most recent insurance card at every visit. Any changes in coverage must be reported prior to treatment.

The patient/legal representative hereby acknowledges that he/she has read, understands and agrees to the financial policy of Saunders Oculoplastic Surgery, PSC.