Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Please let us know if you have any questions or concerns.
Insurance. We participate in several insurance plans; all co-payments and deductibles must be paid at the time of service. If we are not in-network with your insurance company or no insurance information is provided at the time of service, payment in full is expected. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
No refunds on services and custom products. Payment in full is expected before any order is started. Prescription eyeglasses are custom products that are made to order specifically for you and cannot be returned. If there are any issues with the product, we will do our best to address them. All services rendered are provided on a non-refundable basis. You agree not to charge back any credit card payments for custom products or services rendered. In the event of a chargeback or other payment dispute, they will be considered to be in violation of this agreement and may be subject to collection to an outside collection agency.
INSURANCE AUTHORIZATION - SIGNATURE ON FILE
GENERAL RELEASE OF INFORMATION
I give my permission to Scope Optometry to disclose any or all parts of the clinical record to my insurance company(s) for purposes of satisfying charges billed.
ASSIGNMENT OF INSURANCE BENEFITS AND NON-COVERED SERVICES
I hereby authorize payment of benefits directly to Scope Optometry. I understand and agree that I am financially responsible for any charges and services not paid by my insurance company(s).
I permit a copy of this authorization to be used in place of the original.
A contact lens evaluation is an additional fee to the price of a comprehensive eye exam. The fee can range from $75 to $225 depending on the complexity of the fit. Insurance may cover a portion of this fee. (Please ask an associate for the specific details of your plan.) The price includes diagnostic lenses and follow-up phone calls/visits until your contact lens prescription is finalized, up to 90 days from the original exam date. This includes all follow up visits related to the fit of the contacts, and does not include medical visits that may be related to overwear or misuse of contact lenses.
By law in California, a contact lens prescription expires after one year. A contact lens evaluation (including prescription renewals) involves several steps and additional time, and can only be done after a comprehensive eye exam. However, it can be delayed up to 90 days from your last exam.
What is OptoMap?
OptoMap captures ultra-wide images of the retina to show any signs of damage and abnormalities to the back of the eye. This instrument will also enhance our ability to screen for retinal defects relating to glaucoma, cataracts, and macular degeneration. Catching symptoms early on will prevent permanent sight loss.
Some insurance plans cover the imaging, but most plans have a co-pay of $39 for this procedure. (Please ask an associate for the specific details of your plan.)
No Dilation with OptoMap
This technology can be used without dilation and will be a permanent part of your medical records. There are no side effects with this procedure and only takes 2-3 minutes. While retinal imaging does not replace dilation, it provides the most comprehensive view of the retina without dilation available.
The doctor recommends the retinal screening for all patients every year.
We offer this procedure for an additional $39.
No dilation with OptoMap
This questionnaire is meant to help your doctor understand what you’re experiencing on a regular basis — whether it’s caused by your eyes, posture, stress, etc.