Gig Harbor Family Vision has implemented the following safety guidelines in our office:

• Limited doctor's schedule
• First hour reserved for patients who are 60+ years old and high-risk
• All patients to wear a face mask or covering
• Temperatures will be taken upon arrival 
• All patients to use hand sanitizer upon arrival
• Only patients allowed in office without guests unless minor accompanied by guardian or care-giver

There are two types of health insurance that may provide benefits to help you pay for your eye care services. We accept many vision care plans and medical insurances. If we don't bill your insurance directly, we can provide you with an itemized receipt for you to mail in and get reimbursed.

Vision Care plans cover routine vision exams, but are not billable for medical office visits.

Medical insurances cover problem focused medical office visits and may cover routine vision exams as well.

NOTE: Costco Optical has it's own separate insurance panel they bill directly so please inquire with them when checking hardware benefit coverage

The doctors at Gig Harbor Family Vision recommend our Optomap Digital Retinal Imaging system as the preferred method to examine the retina. The Optomap Digital Retinal Imaging provides:

• A more thorough view of the back of your eye (the retina)
• A digital record of the structures of your retina that becomes part of your permanent medical record 
• It is fast, easy, non-invasive, and comfortable
• Helps detect early signs of eye disease (ie. glaucoma, macular degeneration, diabetes, retinal holes)
• Does NOT require dilation drops (which result in blurred vision and sensitivity to light for up to six hours), however, we may also ask that you allow us to dilate your eyes if we feel it is necessary.

I have read this and understand that the Optomap Digital Retinal Imaging  is an important part of a comprehensive eye exam.

The fee for this procedure is $35.00 at the time of your exam.

UPDATE: Dilation requires close face-to-face contact, therefore our doctors highly recommend the Optomap especially during these times.

Financial Agreement 

Eye exam and treatment fees are payable at the time of service. If we bill your vision insurance carrier, you are still directly responsible for any fees they do not pay. If you are covered by any form of managed care insurance that requires prior authorization for our services, you are responsible for obtaining prior authorization. Our staff may assist you in estimating your insurance benefits, however they are never guaranteed. You are responsible for payment of deductibles, co-pays, and non-covered services. Payment may be made in cash or charge. We will apply a 1% statement charge each month to all accounts that are over 60 days past due. Any account that is over 90 days past due will be sent to a collection agency. Thank you for your understanding and cooperation.

Office Policies and Notice of Privacy Practices

• Glasses exams include follow-up visits to fix errors, up to 3 months from your original exam date. After three months, an office visit fee is charged because other factors may influence prescription changes. We do not verify the accuracy of glasses ordered online. Any problems after 6 months, require a new eye exam.
• Contact lens prescriptions require all necessary follow-ups (including new wearer training) before a prescription will be released. Contact lens exams include up to 3 follow-up visits within 2 months.
• I have seen a copy of the HIPAA Notice of Privacy Practices from Gig Harbor Family Vision and/or I am aware a copy of the practices can be provided by request or are viewable online. 
• Arriving 10 minutes late may require rescheduling your appointment.

Electronic Copies of Prescriptions

Copies of glasses and contact lenses prescriptions, at the completion of the exam and/or contact lens assessment, will be provided electronically to the email address on file. A paper copy may also be provided.

IMPORTANT: If you are unable to make your appointment we ask that you call to cancel your appointment at least 24 hours in advance or a $40 NO SHOW/LATE CANCELLATION fee will be charged.

By signing below, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of Gig Harbor Family Vision, and have reviewed their HIPAA privacy policies.