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  • The entire form takes about 3 minutes. You will need your insurance information.

    Thank You!

  • If you have made at appointment with us, please tell us what date and time:

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  • COVID-19 SCREENING

  • Patient Information

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  • Billing Information

  • If you do not see your insurance on the list, you will be responsible for the exam fees. If your insurance has out-of-network benefits, we will provide an itemized statement for you to self-submit your claim; it's easy to do and we'll be able to continue providing your eye care needs!

    Vision plans cover routine wellness exams, but are not billable for medical office visits.
    Medical insurances cover problem oriented medical office visits - they do not include a glasses/contact lens prescription.

    NOTE: Costco Optical has its own panel of insurances it accepts. Please inquire directly with Costco Optical.

  • We are open-access providers for VSP**, Davis Vision, Eyemed, Molina, BlueView, Superior Vision, Cigna, and Humana. As an open-access provider, we are not contracted directly with your insurance but we can provide you with services and still utilize your benefits.


    You would pay for services directly to our office.  We will provide you with an itemized receipt for you to self-submit for payment directly back to you according to your plan rules in 3-4 weeks. 


    **VSP--along with your itemized receipt, we will provide you with the VSP reimbursement form and an envelope addressed to VSP for you to self-submit.


    This will allow us to continue to care for your eye care needs and to utilize your vision benefits.


    ***If this does not work for you, please notify us to cancel your appointment***

     

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  • Health History

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  • Optomap Retinal Exam

  • Our doctors highly recommend the ​Opto​map Retinal Screening to all of their patients for the following reasons:

    • it is a ​non-invasive technique​ to examine the health of your eye, without the side effects of drops or blurry vision
    • it provides a​ high resolution picture​ to compare to in the future
    • The ​Optomap Retinal Screening contributes to our standard of care and improves patient education and satisfaction. There is a nominal charge of $40​ for this procedure, ​that is not​ covered by insurance.

    I have read this and understand that a wide field view of the retina is an important part of a comprehensive eye exam.

    UPDATE: Dilation requires close face-to-face contact, therefore our doctors highly recommend Optos especially during these times to reduce the risks of COVID-19.

  • Office Policies and Notice of Privacy Policies

    • Problems with glasses and contact lenses needing a re-check, are covered for up to 3 months from the ORIGINAL exam date. This does not include post-surgery changes or changes due to medical conditions. Problems between 3-6 months will incur an office visit fee. Problems beyond 6 months will require a new exam.
    • Contact Lens prescriptions are not released until all necessary training and follow-up visits are complete.
    • You allow us to email you electronic copies of prescriptions, invoices, receipts, etc.
    • A $50 no-show fee is charged if you miss your appointment without notifying our office. The fee will be waived for valid concerns.

  • By pressing submit, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of Tacoma Family Eyecare, and have reviewed their HIPAA privacy policies available at www.tacomafamilyeyecare.com

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