PATIENT DEMOGRAPHICS

Optomap & Optical coherence tomography (OCT) are non-invasive tools that take pictures of the back of your eye. The OCT functions like an ultrasound, but uses light waves instead of sound to map the shape of your retina and optic nerve. The Optomap scan gives a panoramic high-quality digital image of your retina. It can potentially replace the need for dilation in some patients and provides a permanent record for annual review. Your doctor highly recommends these additional tests to aid in the diagnosis and management of various eye problems including: Macular degeneration, glaucoma, diabetes and other pahthologies of the eye.

If during the exam, your physician finds one or more of the above mentioned conditions, it may be covered by your insurance.

This screening is NOT covered by your insurance and the cost is as follows:

PLEASE CHECK your selection to enhance your eye exam with the latest technology in eye care. We want to ensure we are offering the most up to date options available.

Payment for services is expected and due at the time of your visit.

The patient is required to provide the most correct and up-to-date insurance information. Patients (or guardian, if minor) are responsible for payment of copays, deductibles, and all other procedures of treatment not covered by their insurance
plan. This includes all overages on materials options and quantities not covered by your vision insurance. Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.
No call/No show appointments: A fee of $50 will be charged for missed appointments that you fail to cancel 24 hours in advance.

Spectacle/Contact Lens Prescription Release Notice 

Pursuant to the Federal Trade Commission’s ruling 16 CFR Part 315: I understand that the practice will readily supply a copy of my non-expired spectacle or contact lens prescription at my request. To abide by HIPAA guidelines, in the absence of a sec electronic submission portal, I understand that this prescription will be available to me by fax or postal mail, or that I may request to pick up the document at the office (allowing a reasonable time frame for office staff to obtain the doctor's signature).

Retinal Imaging is Recommended as a Reference for the Doctors 

Digital retinal imaging provides a detailed documentation of the condition of your inner eye so that the doctor can monitor the changes in your eye health over time. If not medically necessary because of a disease or condition, you agree to the
screening fee selected.

Lifetime Authorization for Insurance Payments 

We request your signature on file, in the event the office files insurance for you or for any office procedure. I request that payment of authorized carrier of benefits be made either to me or on my behalf to this eye doctor for any services furnished me by this/these doctors. I authorize any holder of medical information about me to be released to the carriers any information needed to determine these benefits or the benefits payable for related services.

Notice of Privacy Practices Patient Acknowledgement 

I have had the opportunity to receive this practice’s Notice of Privacy Practices. I understand that the practice may change the terms of its Notice of Privacy Practices and that any changes apply retroactively to information created while the current notice is in effect. I understand I can obtain this practice’s current Notice of Privacy Practices upon request.

Refund Policy for Prescription Eyewear 

We want you to love your new eyewear! If something isn't quite right, we're here to help. Please check out our refund policy below:

Let us know within 30 days of receiving your glasses if there's an issue, and we'll take care of it. Refunds may not be possible for lenses with special coatings or tints made just for you, normal wear and tear or changes in your prescription. Not loving the fit? We offer free adjustments or a one-time replacement if your glasses aren't comfortable, as long as it's within the refund timeframe.

Medicare Does Not Cover the Refraction or Eyewear

As a convenience to our patients, we are a participating provider for Medicare.  We will bill Medicare for your visits.  You may also be responsible for an annual deductible and any non-covered fees.  Each January, Medicare starts with a new deductible that must be met before claims are paid.  If we are the first to file a claim for you this year, it is likely you will not have met your deductible and will owe the full allowed amount.

Medicare does not pay for refractive services.  This is the vision evaluation part of the examination that determines your eyeglass prescription.  Medicare will not pay for routine eye exam services.