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Financial Policies Form

  • Date Format: MM slash DD slash YYYY
  • We are doing everything possible to hold down the cost of medical care. You can help a great deal by reducing the number of bills we send to you. The following is a summary of our payment policy.


    Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. Carolina Ophthalmology Associates accepts cash, personal checks (in-state only), VISA, MasterCard, and American Express. There is a service charge for returned checks.

    Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. We realize that financial difficulty is a reality. In such circumstances, we may advise you to seek your care through a clinic or health bureau.


    We bill participating insurance companies as a courtesy to you. You must present your insurance card at the time of service or you may be subject to the entire balance of your office visit. You have acknowledged that the insurance cards you have presented are current and accurate. Unless you present with an emergency, if you are not able to pay your co-pay, deductible or co-insurance portion at the time of service, your appointment may be rescheduled. You are expected to pay your deductible, coinsurance and co-payments at the time of service. It is your responsibility to know what your co -pay, co- insurance and deductibles are, and it is your obligation to pay these at the time of service. If we have not received payment from your insurance company within 45 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid whether by you or by your insurance carrier.

    Your time of service receipt includes all information necessary for submitting claims to your insurance company.

    We do not file to tertiary insurance (third insurance) companies.

    If you need assistance or have questions, please contact our Billing Coordinator between 8:45 a.m. and 5:00 p.m., Monday through Friday at 919-967-4836 x120.


    The refraction is part of your eye examination. The refraction helps the doctor determine if your vision has changed and the overall health of your eyes. There is a fee of $55.00. Some insurance companies do not cover this fee. Therefore, you are responsible for this fee and due at the time services are rendered.


    Patient/guarantor credits will be retained on account to be credited toward future balances unless a written request for refund is received.


    Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late - canceled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice.

    I have read and understand the Carolina Ophthalmology Associates PA Financial Policy. I agree to assign insurance benefits to Carolina Ophthalmology Associates PA whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections.

    By submitting this form, I certify that I have the legal authority to execute this document and that this submission constitutes a legal signature.

“During a free consultation, Pam explained everything they were going to do. The initial tests, the procedure, the cost and financing options were all explained. The upcoming year I set aside money in my medical savings account so I could go forward with the procedure. The actual LASIK process takes literally seconds per eye to complete. I sat up and could see without glasses or contacts immediately!”

Laura A. Hite, RN, BSN, CDE

See what you’ve been missing!

Stop struggling with your eyesight! Now is the time to schedule your free LASIK consultation with Dr. Bryan and Dr. Shaw at Carolina Ophthalmology and find out if you’re a candidate for laser vision correction. Why not take our Self Evaluation Test to get started?