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  • We're located inside the Elkridge Costco

    Our office is NEXT to the Optical Department. Costco membership is not required for the exam. However, membership is required to purchase glasses/contact lenses.

  • If you need to cancel or reschedule, contact our office 24 hours before your appointment. Otherwise, we do charge a $50 late cancellation or no-show fee.

    Upon arrival, if you are sick and have contagious symptoms, you may be required to wear a mask or cancel/reschedule your appointment. For the safety of our staff and patients, we would appreciate if you call to cancel if you exhibit any symptoms.

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  • If you have not schedule an appointment, please use this LINK TO SCHEDULE and return to this form after scheduling. 

  • PATIENT INFORMATION

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  • Billing Information

    We only bill insurances listed below. If you do not see your insurance, please do not select random insurance. If checking with your insurance company, ask for Dr Jan Eye Care, not Costco.

  • Extra exam services such as contact lens evaluations and Optos retinal photos are not billed to insurance and patients are responsible.

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    SELF-PAY / NO INSURANCE TO BILL

    We accept many forms of payment such as cash, Visa, Mastercard, American Express, Discover, Apple Pay, and FSA/HSA (flexible spending / health savings accounts)

     

    OUT-OF-NETWORK (Davis Vision, Eye Med, VSP, Spectera)

    You pay for the exam fees upfront. We submit the claim for you.
    A few weeks later, your plan sends you a check. We'll do all the work.
    You can be seen sooner with us and still have a great experience. Plus, Costco Optical is in-network for glasses/contact lens material claims.

     

    COSTCO EMPLOYEE INSURANCE

    Employees of Costco along with household members can use their benefits for eye exams as well as red eye exams. 

     

    MEDICARE PART-B

    We do not take HMO plans.
    Note: Medicare is usually for patients over 65 years old. This it NOT Medicaid.

     

  • You selected Self-Pay / No Insurance Billed.

    Please review fees on our website, or contact us for any fee questions.

    If you need an itemized reciept to submit a claim to your insurance, please request at the conclusion of your exam.

  • You selected an out-of-network plan we are not contracted with:

    Although we are out-of-network for your Eye Exam, we can still assist you to utilize some of your benefits. How this works:

    1. You pay for your full exam fees directly to our office
    2. We'll submit the claim to your plan
    3. After a 4-6 weeks, you'll receive a reimbursement check from your plan. The amount is less than an in-network exam but will allow you to utilize some of your benefits.

    Many of our patients elect this route because:

    • We offer appointments within 3 days!
    • We provide great service! See our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.

    You don't have to do anything. Our office will submit the claim. You wait for the check.
     

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  • Health History

  • 1st Time Contact Lens Wearer Exams require multiple visits including:

    - initial visit
    - new wearer insertion/removal training class
    - all necessary follow-ups

    Training classes are often scheduled on another day. However, if a same day training class is available the day, please fill out this FORM.

     

  • For Medical Office Visits or Diabetic Eye Exams:

    These service fees are only billed to medical insurances, not your vision plan which is used for annual wellness checks.

    These services do not include a prescription check for glasses and/or contact lenses. You may pay out-of-pocket for the prescription checks, or schedule another appointment to use your vision plan.

     

    Please contact our office if you need clarification. 

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  • We only fit standard spherical rigid gas permeable lenses. A copy of your previous prescription would be exceptionally helpful.

    If you wear a bitoric, multifocal, keratoconus, orthokeratology, scleral, hybrid or any other speciality fits, our office can not fit you for these types of contact lenses. You can continue with a routine exam without a contact lens fitting, or you may notify us to cancel your appointment.

  • NOTE: If your symptoms make it difficult to check your glasses and/or contact lens prescriptions, we must evaluate/treat the symptoms first as a medical office visit. Then, we will re-schedule your routine exam to check your prescriptions.

  • You selected: NEW FLASHES or FLOATERS.

    You will require a medical office visit instead of a routine eye exam.

    If you are experiencing new flashes of lights, new floaters, or part of your vision is missing (like a web or curtain/veil is blocking your view), please contact our office (or any eye care provider) as soon as possible.

    These symptoms can be a sign of a serious eye condition and may require immediate assistance.

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  • OPTOMAP RETINAL EXAM

  • Our doctors highly recommend the ​Opto​map Retinal Screening to all of their patients, of any age and each year, 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​, that can be compared with future scans
    • it contributes to our standard of care and improves patient education and satisfaction. 

    There is a nominal fee of $35 for this test.

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

  • OFFICE POLICIES and NOTICE OF PRIVACY POLICIES

  • Prescription re-checks: If you have problems with your glasses, we provide complimentary re-checks within 3 months of your exam date. Keep in mind, if no changes are found, a $40 troubleshooting fee will be charged.


    Contact Lens evaluations: include sample diagnostic lenses and up to 3 follow-up visits within 2 months (as needed). Problems beyond 3 months incur additional exam fees, beyond 6 months require a new exam. New wearers require a training course.


    Electronic communications: you allow us to email/SMS appointment reminders, electronic copies of prescriptions, invoices, receipts, etc. We do not share your data.


    $50 no-show / same day cancel fee: arriving too late may require rescheduling, not showing up or cancelling on the day of your appointment, will result in a $50 fee; which must be paid before another appointment is scheduled.


    Payment: is due at the conclusion of the exam. I understand that information obtained from my vision plan and/or medical insurance on my behalf, is not a guarantee of payment or benefits, and that I am obligated to pay any portion of office fees not covered by my insurance company.

    Advanced Beneficianry Notice of Non-Coverage: Medicare and some insurances may not cover services such as Optos retinal screening photos, contact lens evaluations, or refractions. These fees are listed on our website and reviewed with patients. If you receive these services, you agree that we can not bill your insurance for them and you accept responsibility for the fees.

  • By pressing submit, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of DR JAN EYE CARE, and have reviewed their HIPAA privacy policies available HERE.

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