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  • Confidential Patient Information

    Please complete the HIPAA compliant form below.
  •  -
    • Vision change
    • Floaters
    • Flashes
    • Red Eye
    • Dry Eye
    • Watery Eye
    • Burning
    • Soreness
    • Sandy/Gritty
    • Mucus Discharge
    • Eye Pain
    • Foreign Body Sensation
    • Sty or Chalazion
    • Light Sensitivity
    • Droopy Lids
    • Double Vision
    • Glaucoma
    • Macular Degeneration
    • Retinal Detachment
    • Allergies
    • Asthma
    • Headaches
    • Arthritis
    • MS
    • Thyroid
    • Diabetes
    • Cholesterol
    • Lupus
    • High Blood Pressure
    • Heart Problems
    • Kidney Disease
    • Weight Loss or Gain
    • Cancer
    • Other
  • Insurance Information/Policy Holder

  • We accept the following insurance plans: Aetna, Blue Cross Blue Shield, Blue Med, Community Eye Care, Eye Med, Health Team Advantage, Medicare, Medicare Complete, UMR, and VSP. Please list your insurance provider. If your insurance is not listed, we may be out of network and all charges are patient responsiblity. Not all providers are in network.

  • Disclaimer
    This Good Faith Estimate shows the costs of items and services that are
    reasonably expected for your health care needs for an item or service. The
    estimate is based on information known at the time the estimate was created.
    The Good Faith Estimate does not include any unknown or unexpected costs
    that may arise during treatment. You could be charged more if complications or
    special circumstances occur. If this happens, federal law allows you to dispute
    (appeal) the bill.If you are billed for more than this Good Faith Estimate, you have
    the right to dispute the bill.You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
    There is a $25 fee to use the dispute process. If the agency reviewing your
    dispute agrees with you, you will have to pay the price on this Good Faith
    Estimate. If the agency disagrees with you and agrees with the health care
    provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call
    1-800-985-3059.

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