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Vision Plan Information

Vision Plan

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Relationship to Patient:

Medical Insurance Information

Primary Medical Insurance

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Secondary Medical Insurance?

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Financial Information

In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge of $25 on all returned checks. Payment from my vision plan/medical insurance is to be paid directly to Clearfinity Eyecare Optometrist and I understand that (name of vision plan or medical insurance*)

will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made once the claim is processed. All eyewear purchases are final sale and only a store credit can be issued that can be used for any future eyewear purchases.

Financial Information

About your vision plan/Medical Insurance

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts ONE or BOTH:

  1. Vision Care Plans (such as VSP, Davis, Eyemed, etc..)

  2. Medical Insurance (such as Blue Cross/Blue Shield and United Health Care etc..)

  • Vision care plans ONLY cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They DO NOT cover diagnosis, management, or treatment of eye diseases, dry eye, itchy eyes, cataracts, etc...

  • Medical insurance MUST be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

  • If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expenses.

  • We will bill your insurance plan for services if you are a participating provider for that plan. We will try to obtain advanced authorization for your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays, or non-covered services as allowed by the insurance contract.

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Appointment Policy

If you are unable to keep a scheduled eye exam appointment, we ask that you please give us at least 24hrs notice. "Late Cancellation" or "No Show" appointments may be charged $40 on weekdays and $50 on Saturdays.

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Today's Date*

Contact Lens Evaluation Fee

According to the FDA, all contact lenses are considered MEDICAL DEVICES, since they are inserted directly on your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam that includes your eyeglass prescription and is inclusive of all contact lens trial lens follow up visits within 2 months or 60 days from your initial exam or when your contacts are finalized, whichever is first. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this NON-REFUNDABLE fee can range from $149 and up.

​​​​​​​Please check the box and sign below if you need your annual contact lens evaluation/prescription and agree to this fee:

Visual Screening/Retinal Imaging

At Clearfinity Eyecare Optometrist, the doctor believes in providing a yearly complete comprehensive eye examination, which can result in early detection of potential vision threatening and even life- threatening diseases that are not just limited to the eye.

We have a Complete Wellness Screening of your retina that allows the doctor to get a full picture of the function of your optic nerve and help to identify any small changes on the surface or deeper layers of the retina that can be easily missed. The package consists of a visual field test, enlarged digital image of your retinal parts, and an “ultrasound-like” scan of the deeper layers of your retina. The doctor will go over the results in detail at the end of the exam.

Why Should I Do This Screening and Should I Do This Every Year?
is a painless, slow eye disease that causes the death of optic nerve fibers resulting in gradual loss of peripheral vision over time.

Macular degeneration is the loss of central vision due to years of exposure to ultraviolet and blue light from the sun.

Anyone is susceptible to getting glaucoma or macular degeneration but patients who are nearsighted, have a family history of either, or have medical issues like diabetes are at higher risk of acquiring these diseases. If you have hypertension there is risk of macular degeneration due to narrowing of the small artery vessels. Both diseases are painless and is not obvious to you until it is too late.

Therefore, having the full screening as part of your yearly exam is to your best interest in knowing that your eyes are getting properly assessed. It also serves as an initial baseline from which to compare as we follow your eye health in subsequent years. Since these are screening tests, medical and vision plans will not cover it, however any abnormalities that are detected in the screening assessment will result in you returning to the office for a more extensive medical testing that can be billed to your medical insurance minus any contracted co-pays.

The cost of the Complete Wellness Screening is $99 that will give you and the doctor peace of mind that your eyes were thoroughly assessed.

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