Please read and understand before signing.
A refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of an eye examination and necessary to write a prescription for glasses or contact lenses. To minimize residual refractive error following cataract surgery and to reduce your dependence on post-cataract glasses, your doctor needs to perform a refraction as well as other diagnostic tests to assess the refractive state of the eye.
Most medical insurance plans, including Medicare, do not cover routine refractions or routine eye examinations.
Medicare and other commercial insurers allow that we charge separately for that portion of the eye examination, since it is not a covered service. If you have any questions regarding Medicare and insurance policies or procedures, do not hesitate to ask. We will do our best to assist you.
By signing this form, you are acknowledging if your insurance does not cover this service, you will be billed the $43.00 fee, in addition to any co-payment your insurance may require.