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Included below is important information to review prior to receiving your contact lens prescription.
The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free— especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment."
The CDC recommends the following for contact lens wearers:
The Food and Drug Administration (FDA) indicates:
Symptoms of Eye Infection include:
Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.
By signing below, I give Maine Optometry, P.A. my permission as the Patient/Legal Guardian/POA to release my Personal Health Information (PHI) in accordance with established H.I.P.A.A laws for the following:
To release any information regarding my diagnosis and care to my primary care physician (PCP) and any other physicians involved in managing my conditions.
To act on my behalf regarding any and all contact with my insurance carrier(s) and also to release any information regarding my diagnosis and care with the primary insurance carrier and any other supplemental insurance carriers.
I acknowledge that I have read and understand all aspects of the policies explained above.
Co-Payments: Your co-payment is due at time of service.
Self-Pay: Patients with no insurance coverage are expected to pay, in full, at the time of service.
Optomap® Retinal Imaging Fee: As a part of our standard of care beginning in 2023, we perform the Optomap® Retinal Imaging during all routine eye examinations. These scans provide an in-depth view of the retina and allow us to do a side- by-side comparison year over year. This information is crucial for us to monitor your eye health. Insurance typically doesn't cover the cost of advanced screenings, and a fee of $20.00 is due at the time of service. If the doctor determines a medical finding, the cost of these images will be billed to your medical insurance. Maine Optometry will provide this service free of charge for patients who are 8 years and under.
Outstanding Balances: Payment is due upon receipt of statement. Balances not paid within 90 days of the initial billing may be subject to a $15 per month late fee. In the event the account is past due after 90 days, the account may be sent to a collection agency.
Eyewear/Lens/Contacts Lens: Purchases must be paid in full at the time of order. We will gladly hold your order with a 50% deposit and the order will be placed upon receipt of full payment. Upon pickup, final cost of eyewear/lens may have a small balance due or credits due to variations of insurance company’s final rates.
Returned Checks: Checks returned for insufficient funds (NSF) will incur a $25.00 charge and we will automatically redeposit the check. If the check is returned a second time, another $25.00 service charge, plus the face value of the check will be charged back to the patient’s account and will be due immediately in an alternate form of payment.
Account Credits: Any credits on a patients account that are incurred will not be subject to automatic refund of $40 or below.
Medical Diagnosis: Please be advised that most insurance companies do not consider treatment for a medical diagnosis by an optometrist to be a Routine Eye Exam. These services will be billed to your medical insurance carrier and subject to their terms and conditions.
Cancellation and No-Show Policy: Patients are requested to cancel or reschedule their appointments at least 24 hours in advance to allow the practice enough time to reschedule the time slot. However, we understand that this may not always be possible and allow for one cancellation under 24 hours or one no-show within a 24 month period. The practice retains the right to refuse scheduling or dismissing patients from the practice that have incurred three or more violations of the policy within a 24 month period. New patients or patients that have not been seen in the previous 36 months that have two or more violations will be dismissed for failure to establish as a patient.
I hereby acknowledge that I have read and understand the above information.