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  • Financial Policy:

    Initial and Sign below
  • All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.

    Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided.
  • I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party to accepts assignment.

    I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.
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  • HIPAA Acknowledgement Receipt:

    The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy.
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  • Screening Wellness Testing:

    While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina and visual field is critical to evaluate the optic nerve and retina. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The exam is quick, painless, and may not require dilation drops. These tests are in addition to the routine examination and are discounted to insurance allowable fee of $39.00. Each test separately is $20.00 each. If you choose to have these important screening tests, this amount will be due from you today.