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Office Policy

1. In the event my insurance provider determines that I am not eligible for visual insurance coverage or eligible for a reduced level of coverage, by signing this statement, I hereby agree to be financially responsible for any and all charges incurred by me and not paid by my insurance provider.
2. I acknowledge receipt of a copy of Eye Heart Vision's Notice of Privacy Practice.
3. I understand all fees of services rendered are due and payable at the time of service.
4. I understand fees paid for services are non-refundable.

If you are a current contact lens wearer or are interested in wearing contact lenses, you will need a contact lens evaluation.

The goal of a contact lens evaluation (fit) is to find the most appropriate contact lens for each patient's optimal vision and comfort. Before a person can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use.

The contact lens evaluation (fit) fee is not included in the fee for your eye exam and is usually not fully covered by your insurance.

The fee for your contact lens evaluation includes the initial visit and visits directly related to contact lens wear within a 90 DAY PERIOD. The fee also includes a contact lens training class for new wearers. The fee is due in full at the time of the fitting evaluation and is a non-refundable service rendered.

The doctor will examine the health of your eyes annually to ensure that you are a proper candidate for contact lenses.

You are responsible for scheduling and attending your follow up visit to finalize your prescription. Without a finalized prescription, you will not be able to order contacts

While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, retinal detachments, macular degeneration, high blood pressure, and even tumors.

Optomap Daytona is a non-invasive procedure that is quick, painless, and does not require dilation drops. This procedure allows your doctor to see a much broader and more detailed view of the retina, in most cases, without the need to dilate. After reviewing the images, they become a permanent part of your medical file and will be used to monitor your eye health and overall wellness from year to year.

The fee for the Optomap procedure is $35 (covers both eyes).

This is a diagnostic procedure that also allows a more complete assessment of the internal health of the eyes. Dilation involves placing drops in your eyes that will enlarge your pupil. The side effects are blurred near vision (for approximately 4-6 hours) and light sensitivity. In some individuals, the distance vision may also be blurred.

The fee for this additional procedure is $25 (Note that this service is fully covered by most vision/medical insurances).

Liability Release: I have been informed by Eye Heart Vision of the importance of having a comprehensive retinal eye examination annually in the detection and diagnosis of eye disease.  I understand that I can have my retinas examined either by the Optomap procedure and/or by having my eyes dilated.  I am declining the doctor's recommendations to obtain a comprehensive view of my retinas.  By foregoing both the Optomap and dilation procedures, I do not hold Eye Heart Vision responsible for any disease or pathology that goes undetected due to the lack of diagnostic information that could have been obtained by these testing procedures.