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.

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 expense.
• We will bill your insurance plan for services if you we are a participating provider for that plan. We will try to obtain advanced authorization of 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.

I have read and agree with these policies:

According to the FDA, all contact lenses are considered a MEDICAL DEVICE, 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 $129 and up.

A Routine Eye Exam is focused on assessing and maximizing vision along with a general health assessment of your eyes. However, there is additional state-of-the-art technology, beyond just dilating your eyes, that we offer that can allow for a more thorough evaluation that can uncover any EARLY signs that may be missed until TOO LATE.

Ocular Coherence Tomography (OCT) is an advanced eye scan that uses light to illustrate the different layers that make up the back of the eye – like assessing the inner layers of a sandwich beyond the bread. A detailed 3D image below the surface of your retina is produced, giving the doctor a deeper, detailed picture of your eye health. The scan is non-invasive, painless, simple and quick.

It can help the doctor measure and monitor for any early retinal tissue, macula, or optic nerve disease. It can mathematically show any changes from one visit to the next.

This image is stored on our computer and in your electronic health record giving you an invaluable continuous record of the health and condition of your eyes.

What can the scan check for?

Common conditions identified through regular OCT screening: - Early Age Related Macular Degeneration

• Early Glaucoma
• Diabetes Retinopathy
• Macular Holes/Edema

A Wellness Retinal imaging Screening allows the doctor to look at a magnified view of the retinal and optic nerve tissue (the bread of a sandwich). This allows the doctor to catch very small defects that may be missed looking at a moving eye ball and can track for any changes in the appearance of the retina over time.

The Visual Field Screening is an interactive test that allows the doctor to check the actual function of the visual system from the optic nerve to the brain (the part the doctor cannot see).

The OCT, Retinal Imaging, and Visual Field Screenings are additional tests that are not part of a normal eye exam. All screening program/tests are NOT COVERED BY MEDICAL INSURANCE.

All three screenings together help the doctor to get a COMPLETE PICTURE/FUNCTION of your EYE HEALTH and identify possible issues that may be missed and is strongly recommended. If any abnormalities are found you will be scheduled for a medical evaluation and a more extensive testing program will be implemented to dive deeper into the issue. Please select the following: