ALL payments for services including co-payments, deductibles, consultation fees and additional service or treatment fees are to be paid on the same date of service. Acceptable forms of payment include cash, credit card (Visa, MasterCard, American Express, Discover) or a certified bank check. Please make sure to bring an acceptable form of payment with you at the time of your appointment – failure to do so may result in cancellation of your appointment.

We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may not accept information from our office and may need information from you. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and the insurance company; we are not party to that contract.

The cost of a visit for a patient without insurance or with insurance with which our office does not participate is $400. There may be additional charges depending on additional testing performed during your visit. You may inquire about those services prior to your visit.

I authorize the release of all medical information necessary to process this claim and that is pertinent to my medical care. I assign all medical and /or surgical benefits, including major medical benefits to which I am entitled, to the provider of services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

Dagan MD NYC accepts assignment and participates in most major insurance carrier plans. lf the patient’s insurance policy is not a plan Dagan MD NYC or its providers participate in, Payment in full is expected at each visit. Knowing your insurance benefits is your (the patient’s) responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit prior to your visit. If you do not see your plan in the list below, please call your insurance to find out if we participate with them. Always check your out of network benefits as well.

I request the payment of authorized Medicare benefits be made to me or on my behalf to the provider for any services furnished to me by that provider. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, any information needed to determine benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

We currently do not accept assignment or participate in any Medicaid plan. If you have a Medicaid plan or a Medicaid sponsored plan with a private carrier you will be responsible for the charges of your visit and any incurred charges according to our fee schedule that is available to you. Please inquire with our staff to provide the pricing of the medical visit and any additional tests before your visit.

lf your account is more than 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance has remained unpaid, it may be sent to a collection agency. lf an account is sent to collection, it is the policy of this office to discharge the patient and possibly immediate family members from the practice. You will at that time be notified by regular and certified mail that you will have 30 days to find alternative medical care. During that 30-day period our practitioners will see you on an emergency basis only with payment in full for each visit. You will be responsible for the charges of collection including all legal costs that may be incurred in addition to your bill. A daily periodic Rate (DPR) penalty of 10% shall be accrued to these charges.

All patients must complete our patient information form, which will be entered into our computer to maintain accurate information for proper billing. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. lf you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of a claim. Most insurance companies have timely filing restrictions; if a claim is not filed within 30 days of the date of service, it can be rendered ineligible for payment and you will be responsible for the balance that remains.

We currently participate in network with the following insurance plans/companies:

• 1199SEIU
• AARP
• Aetna
• Aetna Medicare Advantage
• American Republic Insurance Company
• Anthem Blue Cross Blue Shield
• Assurant Health
• Blue Cross Blue Shield
• Blue Cross Blue Shield Employee Program
• Bright Health
• CareFirst Blue Cross Blue Shield
• Cigna
• Emblem HIP
• Emblem 1199
• Empire Blue Cross Blue Shield
• Empire Blue Cross Blue Shield Medicare Advantage
• HIP Commercial
• HIP Medicare Advantage
• Horizon Blue Cross Blue Shield of New Jersey
• Humana
• MagnaCare
• Medicare
• Oscar
• Oxford (UnitedHealthcare)
• Premera Blue Cross
• UnitedHealthcare
• UnitedHealthcare Oxford
• Wellmark Blue Cross Blue Shield

We are affiliated with the following hospitals:

New York

• New York Eye and Ear Infirmary of Mount Sinai
  310 E 14th St, New York, NY 10003
  Tel: (212) 979-4000

• Mount Sinai Beth Israel Medical Center
  281 1st Avenue, New York, NY 10003
  Tel: (212) 420–2000

• Manhattan Eye Ear and Throat Hospital (Northwell)
  210 E 64th St, New York, NY 10065
  (212) 838-9200

• Lenox Hill Hospital (Northwell)
  100 E 77th St, New York, NY 10075
  (212) 434-2000

• Staten Island North University Medical Center (Northwell)
  475 Seaview Ave, Staten Island, NY 10305
  (718) 226-9000

New Jersey

• Hudson Regional Hospital
  55 Meadowlands Pkwy, Secaucus, NJ 07094
  (201) 392-3100

Kindly give our office 24 hours notice if you are unable to keep your scheduled appointment.  We make every attempt to confirm appointments the day prior via phone and email confirmation.

For all consultations appointments, a $100 cancellation fee will be applied for missed appointments or cancellations within 24 hours of the appointment.

In the event of true emergency, exceptions may be made.

If you have booked your appointment online, you have 24 hours to cancel your appointment after booking it. Cancelling your appointment more than 24 hours after online booking on any site will incur a $100 cancellation fee.

Please understand that another patient may be able to use your cancelled slot.