Mack Eye CenterPrinze Mack, M.D.Shiza Sarfraz, O.D.
257 Monmouth Road, Suite 1BOakhurst, NJ 07755
192 Jack Martin Blvd, Unit B4Brick, NJ 08724
(732) 835-2020www.mackeye.comNOTE: If you need to send records from any other doctor visit, please contact your other doctor'soffice today and have the records faxed to us at (732) 730-5096.
1 Please fill out all fields.
5 If Yes, enter your new MEDICAL insurance information below,
I acknowledge that my updated medical and insurance information is accurate.
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.
REFRACTION AND CONTACT LENS FITTING POLICY
REFRACTION POLICY:
During your visit, a refraction may be performed to determine your need for glasses or to evaluate if any further visual improvement can be achieved. This is a necessary and essential portion of your eye exam and in some cases it is the sole reason for the appointment.
However, the refraction is considered a NONCOVERED service by Medicare and many Commercial Insurance plans.
Our office collects the $40 refraction at the time of service.
If your primary or secondary insurance pays us for the refraction, we will CREDIT your account. This will be determined when we receive the Explanation of Benefits.
CONTACT LENS POLICY:
The glasses prescription you receive from the Mack Eye Center is NOT a contact lens prescription.
The doctor must examine and fit you with the contact lenses on your eye(s).
A refraction is necessary prior to a contact lens evaluation.
All Soft Contact Lens examination patients will receive a new bottle of approved Contact
Lens Multipurpose solution and new case.
There is a fee for this service, even if you are an established contact lens wearer. Similarly to the refraction policy, the fitting fee is due at the time of service as below. After your contact lens fitting is completed and services incurred are paid for, you will be able to order contact lenses through the Mack Eye Center or be provided with a copy of your contact lens specifcation.
*NEW Contact Lens patients: To avoid corneal trauma, if you cannot successfully insert the contact lenses in within 20 minutes, we will reschedule you for another training within 1 week. If you require more than 3 sessions to master insertion and removal of the contact lenses, you will be subject to an additional $45 for 3 more sessions. No refunds if the training is unsuccessful.
*NEW Multifocal Contact Lens patients: You will have an opportunity to change your contact lens brand up to 3 times. An additional fee of $45 will apply if you need more sessions.
I have read and understand the above refraction and contact lens fitting policy.
Ordering Eyeglasses and Contact Lenses
Both locations of the Mack Eye Center offer fashionable Eyeglasses in our Optical Shops as well as Contact Lens ordering.
Our office maintains reasonable prices for Eyeglasses that are competitive with major big box retailers such as Lenscrafters and Pearle Vision, and our Contact Lens prices are very competitive against major online retailers such as 1800Contacts.
Our optical shop can custom make Eyeglasses and have them ready for pickup in about 1 week, and Contact Lens orders can be shipped to your home or office.
I have read the Eyeglasses and Contact Lens form.
Billing and Financial Policy
PLEASE READ AND SIGN BELOW:
FINANCIAL POLICY: The following is a statement of our financial policy.
1. Patient Information: All patients must complete all of our Patient Information sheets and this form before seeing the doctor. Unless previous arrangements have been made, all payments are due at the time of the appointment. Payment can be made with cash, check, Visa, or Mastercard. We will only bill insurance carriers with whom we participate (have a signed agreement with).
2. Participating Managed Care Insurance: You are responsible to supply our staff with your primary and/or secondary insurance ID card(s) at the time of your appointment. If your insurance company requires a referral from your primary doctor, you must also present this to our receptionist prior to being seen, as we cannot bill your insurance without it. If you do not obtain a referral when your insurance requires one, you will be required to pay for the visit in full. If your insurance requires a copay, it must be paid at the time of the appointment.At times, your insurance carrier will deny payment for authorized services. If so, you may be asked to help resolve these issues with your carrier. If you have a deductible, you will be responsible for paying the full amount of the deductible as it pertains to your visit.
3. Non-Participating Insurances: If we do not participate with your insurance, the bill is your responsibility and is due at the time of service. Payment can be made with cash, check, Visa, or Mastercard.
4. Medicare: We participate with Medicare. We will submit your claim to Medicare. The 20% difference between what Medicare “allows” and what Medicare “pays” will be sent to yoursecondary insurance if you have one, or to you. You are also responsible for the payment of your yearly deductible.
5.Returned checks: A Fee of $25.00 will be added to your bill if this occurs.
6. Cancellations: If you are unable to keep your scheduled appointment, 24 hours notice of cancellation is required. Otherwise a $25 fee will be made for the time that was reserved for you.
7. Collections: Any outstanding balance for which the patient is responsible is due within 30 days. For every 30 days an account is overdue, a late fee of $15 will added to the account. For accounts that go unpaid past 90 days, late fees will cease and the balance will be sent immediately to collections with a 25% charge.
Thank you for your cooperation in understanding our financial policy. I have read the above Mack Eye Center financial policy and I understand and agree to abide by its terms.
I have read the billing policy and understand and agree to its terms.
