SODO Vision - Patient Intake Form Logo

  • Located inside the SODO Costco, at 4401 4th Ave S, Seattle, WA 98134

    Our office is NEXT to the Optical Department. Costco membership is not required for the exam. However, membership is required to purchase glasses/contact lenses.

  • If you need to cancel or reschedule, contact our office 24 hours before your appointment. Otherwise, we do charge a $50 late cancellation or no-show fee.

    Upon arrival, if you are sick and have contagious symptoms, you may be required to wear a mask or cancel/reschedule your appointment. For the safety of our staff and patients, we would appreciate if you call to cancel if you exhibit any symptoms.

  • Due to the holiday season, Costco parking is very busy. Please ensure you arrive early to make it to your appointment on time.

  • PATIENT INFORMATION

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  • If the patient is under 18, a guardian over 18 years old must be present at the exam or must call our office as soon as possible to give consent for the exam.

    If no parental presence or consent is given by the time of the exam, the appointment will be canceled, and a fee will be charged due to cancellation.

  • Please contact us if your child does not know their ABCs or numbers well. We may need to cancel this appointment and recommend a pediatric office.

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  • Billing information

    We only bill insurances listed below. If you do not see your insurance, please do not select a random insurance. If checking with your insurance company, ask for SODO Vision Care, not Costco.

  • We only bill your primary insurance. We do not coordinate with secondary insurances.

    Extra exam services such as contact lens evaluations and Optos retinal photos are not billed to insurance and patients are responsible.

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    SELF-PAY / NO INSURANCE TO BILL
    We accept many forms of payment such as cash, checks, Visa, Mastercard, American Express, Discover, Apple Pay, and FSA/HSA (flexible spending / health savings accounts)

     

    OUT-OF-NETWORK VISION SERVICE PLAN (VSP)
    Although you pay a higher out-of-network co-pay, you can be seen sooner, we provide great service, and Costco Optical is in-network for your glasses/contact lens claims.

    We submit the claim, and our office will await payment from VSP. You don't have to do anything.

    Includes: Amazon, Metlife, Swedish Health, Delta Dental, Alaska Air, Delta Air, Google, University of WA
    We can not bill: Molina, SEBB school plans.

     

    OUT-OF-NETWORK (Davis Vision, Eye Med, Superior)
    You pay for the exam fees upfront. We submit the claim for you.
    A few weeks later, your plan sends you a check. We'll do all the work.
    You can be sooner with us and still have a great experience. Plus, Costco Optical is in-network for glasses/contact lens material claims.

    Includes: Boeing (Davis Vision ID# 789xxxxx)
    We can not bill: SEBB school plans.

     

    COSTCO EMPLOYEE INSURANCE

     

    FIRST CHOICE HEALTH

     

    KAISER ACCESS PPO
    Your ID card must say ACCESS PPO on it. We do not accept other Kaiser plans.

     

    MEDICARE PART-B
    We do not take HMO and Advantage plans.
    Note: Medicare is usually for patients over 65 years old. This it NOT Medicaid.

     

    NORTHWEST BENEFITS NETWORK

     

    PREMERA / LIFEWISE
    Amazon employee's Premera plan outsources to VSP for wellness exams; see VSP above.
    Plans starting with “R” or say Federal Employee Program Blue Vision are not billable by our office.

     

    REGENCE = VSP listed above
    Regence outsources to VSP for wellness exams. It likely shows VSP on the back.
    We only bill Regence for medical office visits, which do not check for prescriptions.



    RGA / HMA
    This is not the same as Regence Blue Shield listed above.

     

    SPECTERA VISION (www.spectera.com)
    This is the only commercial United Health Care product we take.
    Includes: some Medicare AARP plans

     

    APPLEHEALTH PLANS
    Wellpoint / Amerigroup (www.dentaquest.com/vision/members/)
    March Vision - (https://www.uhccommunityplan.com/)
    Community Health Plan of WA (https://www.chpw.org/ - under 21 years only)
    We do not take Molina or Coordinated Care

     

    Many out-of-state Blue Cross Blue Shield plans out source their benefits to VSP, Eyemed, BlueView, etc. Please email your ID cards to info@sodovisioncare.com for us to research ahead of time.

  • You selected Self-Pay / No Insurance Billed.

    Please review fees on our website, or contact us for any fee questions.

    If you need an itemized reciept to submit a claim to your insurance, please request at the conclusion of your exam.

  • You selected Out-of-network Vision Service Plan.

    We want this to be transparent, we are out-of-network for your Eye Exam, so you'll pay a higher co-pay (plans vary but approximatley $65 for the wellness exam: additional services such as contact lenses, Optos photos, etc are patient responsbility).

    Many of our patients elect this route because:

    • we offer appointments within three days!
    • we provide great service! see our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.

    You don't have to do anything. Our office will submit the claim.

  • You selected an out-of-network plan we are not contracted with:

    Although we are out-of-network for your Eye Exam, we can still assist you to utilize some of your benefits. How this works:

    1. You pay for your full exam fees directly to our office
    2. We'll submit the claim to your plan
    3. After a 4-6 weeks, you'll receive a reimbursement check from your plan. The amount is less than an in-network exam but will allow you to utilize some of your benefits.

    Many of our patients elect this route because:

    • we offer appointments within three days!
    • we provide great service! see our Google Reviews.
    • Costco Optical is in-network for your Materials: Glasses and/or Contact Lenses.

    You don't have to do anything. Our office will submit the claim. You wait for the check.


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  • Applehealth plans have two ID cards (ProviderOne and HMO)

    We do not need this ProviderONE card:


    We need one of these HMO cards:

  • Most Regence ID cards will show VSP on the back.

    This means your Regence plan outsources vision benefits to Vision Service Plan (VSP), which we are out-of-network with.

    Please read the VSP section for more info.

  • Regence Group Administrations (RGA) is not the same as  Regence.

    Do not select RGA if you have Regence.

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  • HEALTH HISTORY

  • 1st Time Contact Lens Wearer Exams require multiple visits including:

    - initial visit
    - new wearer insertion/removal training class
    - all necessary follow-ups

    Training classes are often scheduled on another day. However, if a same day training class is available the day of your initial visit, this secondary website and form must be filled out. Please fill it out after you complete the Patient Intake Form: https://www.sodovisioncare.com/newclwearer

  • For Medical Office Visits or Diabetic Eye Exams:

    These medical service fees are only billed to medical insurances, not vision plan used for annual wellness checks.

    These services do not include a prescription check for glasses and/or contact lenses. You may pay out-of-pocket for the prescription checks, or schedule another appointment to use your vision plan.

    Please contact our office if you need clarification.


  • The new wearer contact lens evaluation occurs over a few return visits and includes:

    • a required new wearer insertion and removal, care and compliance training session(s)
    • any necessary follow-up visits to ensure optimal health, comfort, and vision
    • after all the steps are complete, then a prescription will be released.

    The training session will usually not be on the day of your exam.

    Follow-up visits are included in your contact lens evaluation fees.

  • The 'working distance' of reading and/or computer glasses is how far from your face that you like to perform these activities.

    Our standard measurement for near/reading/laptop activities is set for 16".

    Our standard measurement for desktop computer activities, is set for 24".

    If you prefer to hold objects outside of these standard working distances, please measure and provide that info below. Otherwise, your prescriptions may not work well.

  • We only fit standard spherical rigid gas permeable lenses. A copy of your previous prescription would be exceptionally helpful.

    If you wear a bitoric, multifocal, keratoconus, orthokeratology, scleral, hybrid or any other speciality fits, our office can not fit you for these types of hard contact lenses. You can continue with a routine exam without a contact lens fitting, or you may notify us to cancel your appointment.


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  • You selected: NEW FLASHES OF LIGHTS.

    You will require a medical office visit instead of a routine eye exam.

    If you are experiencing new flashes of lights, new floaters, or part of your vision is missing (like a web or curtain/veil is blocking your view), please contact our office (or any eye care provider) as soon as possible.

    These symptoms can be a sign of a serious eye condition and may require immediate assistance.

     

  • NOTE: If your symptoms make it difficult to check your glasses and/or contact lens prescriptions, we must evaluate/treat the symptoms first as a medical office visit. Then, we will re-schedule your routine exam to check your prescriptions.

     














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  • OPTOMAP RETINAL EXAM

  • Our doctors highly recommend the ​Opto​map Retinal Screening to all of their patients, of any age and each year, for the following reasons:

    • it is a ​non-invasive technique​ to examine the health of your eye, without the side effects of drops or blurry vision
    • it provides a​ high resolution picture​, that can be compared with future scans
    • it contributes to our standard of care and improves patient education and satisfaction. 

    There is a nominal fee of $30 for this test.

    I have read this and understand that a wide field view of the retina is an important part of a comprehensive eye exam.

  • OFFICE POLICIES AND NOTICE OF PRIVACY POLICIES

    • Prescription re-checks: If you have problems with your glasses, we provide complimentary re-checks within 3 months of your exam date. Keep in mind, if no changes are found, a $40 troubleshooting fee will be charged.
    • Contact Lens evaluations:  include sample diagnostic lenses and up to 3 follow-up visits within 2 months (as needed). Problems beyond 3 months incur additional exam fees, beyond 6 months require a new exam. New wearers require a training course. 
    • Electronic communications: you allow us to email/SMS appointment reminders, electronic copies of prescriptions, invoices, receipts, etc. We do not share your data.
    • $50 no-show / same day cancel fee: arriving too late may require rescheduling, not showing up or cancelling on the day of your appointment, will result in a $50 fee; which must be paid before another appointment is scheduled.
    • Payment: is due at the conclusion of the exam. I understand that information obtained from my vision plan and/or medical insurance on my behalf, is not a guarantee of payment or benefits, and that I am obligated to pay any portion of office fees not covered by my insurance company.
    • Advanced Beneficianry Notice of Non-Coverage: Medicare and some insurances may not cover services such as Optos retinal screening photos, contact lens evaluations, or refractions. These fees are listed on our website and reviewed with patients. If you receive these services, you agree that we can not bill your insurance for them and you accept responsibility for the fees.

  • By pressing submit, I acknowledge I have read the entirety of this form, am aware and agree to the office policies of SODO Vision Care, and have reviewed their HIPAA privacy policies available at https://www.sodovisioncare.com/readme

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