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

• All patients to wear a face mask COMPLETELY covering both nose and mouth
• Only patients allowed in office without guests unless minor accompanied by one 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 medical insurances and some vision care plans. If we don't bill your insurance directly, we can provide you with an itemized receipt for you to mail in and get reimbursed according to your plan.

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. Medical office visits address issues such as eye infections, flashes/floaters, dry eyes, cataracts and diabetic eye exams.

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

ATTN: If unable to upload copies of insurance cards, please select "No insurance" to bypass the requirements and bring in your cards to scan in at your appointment. Thank you.

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.

ATTENTION PATIENTS WITH DIABETES: For patients that require a diabetic eye health exam, dilation and Optomap Imaging will both be performed. This exam may be scheduled on a different day from your routine eye exam visit. 

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.

COVID-19 UPDATE: Dilation requires close face-to-face contact, therefore our doctors highly recommend the Optomap Imaging 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 for prescription checks, 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 and DO NOT provide pupillary distance measurements.  Any problems after 6 months, require a new eye exam.
• Contact lens prescriptions may require necessary follow-ups before a prescription is released. Contact lens exams include up to 3 follow-up visits within 2 months.  For new contact lens wearers, a $30.00  training session is required on a separate visit.
• 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. 
• IMPORTANT : To provide the best care, 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  $40.00 NO SHOW/LATE CANCELLATION  fee will be charged.  In order to reschedule, this fee is collected.
• Arriving 10 minutes late may require rescheduling your appointment.

Electronic Copies of Contact Lens Prescriptions

A Copy of contact lens prescription, at the completion of the exam and/or contact lens assessment, will be provided electronically to the e-mail address on file. A paper copy of both glasses and contact lens presciption will also be provided once finalized by the doctor.

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.