CONTACT LENS FEES - Contact Lenses are medical devices that are worn on a living tissue. A contact lens exam consists of a thorough evaluation of your vision, your cornea (where the lens sits), your eyelids, as well as additional evaluations not included in a routine eye exam. Evaluation fees are established according to the complexity of the case and the estimated time necessary to care for the individual patient. Fees for contact lens services in addition to exam cost are: Spherical/Basic Toric Wearer $55.00, High Rx Toric Wearer $75, Bifocal / Monovision Wearer $85.00, New Contact Lens Wearer with insertion and removal training $85.00, RGP Lens Wearer $95. All fees include trial lenses and any and all follow up exams needed for 60 days.
HIPAA – I acknowledge and agree that I have been informed that this office abides by the HIPAA laws and am entitled to a copy of the Notice of Privacy Practices for review and, if desired, to keep for my records on the date identified below.
FINANCIAL POLICY – I understand that payment for all services, co-pays and materials is due at the time of my visit. I authorize the release of any information required to process an insurance claim. I understand that I am responsible for any amounts not paid by my insurance company.
Dilation is an important part of a complete eye exam. Dilation will make your pupil large so that doctor can get a better look at the back of the eye to check for any problems that can occur due to the following: • Systemic Diseases, such as Diabetes, High Blood Pressure, Cancer, etc. that can affect the eyes without obvious symptoms to the patient.• Physical Changes in your eyes, such as cataracts, glaucoma, retinal detachment, etc. that can affect your vision.
The dilation will make reading things up close difficult, and make lights seem brighter than usual. This will last for 4‐5 hours, although it can last longer in some people. Most people will be able to drive once their eyes are dilated, as long as they have sunglasses (which we can provide). However, if you feel uncomfortable driving, or have never driven with your eyes dilated, it may be best to have a driver. Please note there is NO additional charge for having your eyes dilated.
It is highly recommended to have your eyes dilated if: *You are new to our office. *You are diabetic. *You are over age of 60. *You have a prescription over ‐6.00. *Have been previously diagnosed with a condition of the eye that needs yearly monitoring.
**In refusing to have my eyes dilated, I understand that I am assuming all risks associated with failure to diagnose eye conditions due to lack of information, which may have been provided by this test. I understand that these conditions could result in partial or total blindness.