Please read and understand before signing. By signing this form you are acknowledging that we will collect $45.00 during your visit today.
A refraction is the method to determine the best visual acuity achievable of an individual. It is the first step in determining whether an individual has a potentially harmful medical condition relating to their eyes and vision. Also, a refraction is the process of determining if there is a need for corrective
eyeglasses or contact lenses. It is an essential part of an eye examination and necessary to write a prescription for glasses or contact lenses. For these reasons, refraction will be performed at every eye examination.
Most medical insurance plans, including MEDICARE, do NOT cover refractions or routine eye examinations. Medicare allows that we charge separately for that portion of the examination, since it is not a covered service.
Our office fee for a refraction is $45.00 and this fee is collected at the time of service, in addition to any co-payment your insurance plan may require. Refraction fees will NOT be billed to your insurance company.
If you have any questions regarding Medicare and insurance policies or procedures, please do not hesitate to ask. We will do our best to assist you.
I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service and understand that payment is due at the time of service. I understand that any co-payment, co-insurance or deductible I may have are separate from and NOT included in the refraction fee.