Your MEDICAL INSURANCE is billed for MEDICAL conditions (diabetes, red eyes) and your VISION plan is billed for VISION related services (glasses). These visits might also have to be billed over SEPERATE visits. These are the guidelines dictated by the insurance companies.
All professional services are non refundable.
I UNDERSTAND I AM RESPONSIBLE FOR KNOWING THE BENEFITS MY INSURANCE PROVIDES.
BY SIGNING BELOW, I HEREBY AUTHORIZE EYES ON EVESHAM, LLC, TO DISCLOSE ANY NECESSARY INFORMATION; TO ANY PHYSICIANS FOR THE PURPOSE OF PROVIDING CONTINUING PROFESSIONAL CARE AND TO ANY INSURANCE COMPANY/THIRD PARTY PAYER, FOR THE PURPOSE OF OBTAINING PAYMENT TO EYES ON EVESHAM, LLC FOR SERVICES PROVIDED.
I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO EYES ON EVESHAM, LLC.
IF PAYMENT IS DENIED BY THE INSURANCE COMPANY I AGREE TO BE PERSONALLY AND FULLY RESONSIBLE FOR PAYMENT.
BY SIGNING BELOW; I ACKNOWLEDGE AND ACCEPT THE TERMS AND CONDITIONS SET FORTH ON THIS FORM.
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.
a) For the purpose of providing Targct Optical coupons and service and product information either from this office or directly from Target Optical; and
b) To compare contact lists with Target Optical to help avoid duplicate contacts related to eye exam scheduling within similar time frames.
By signing below, I acknowledge receipt or the opportunity to review the Notice of Privacy Practices of Eyes on Evesham, LLC. In addition by signing, I authorize Eyes on Evesham, LLC to disclose my health information in conformance with the provisions of the Notice of Privacy Practices.
I have the right to withdraw or revise my permission at any time in writing
To whom, other than yourself, may we speak to regarding your condition/results?
At Eyes On Evesham, doctor Gaithri Ramanathan, O.D., F.A.A.O. recommends optomap retinal imaging.
optomap retinal imaging:
optomap scans for ocular and systemic conditions including but not limited to:
A contact lens is a medical device in contact with the tissues in the eye; therefore, it must fit appropriately to maintain the health of your eyes. A contacts lens prescription can only be determined by the careful observation of the lens on the eye and the eye’s response to the lens on follow up visits. All contact lens prescriptions must be finalized within 3 months. Since follow up care is essential, it is your responsibility to schedule and keep appointments and follow all lens care instructions.
We will not finalize the contacts lens prescription until both the patient and doctor are satisfied with the fit and visual acuity of the contact lens.
A contact lens prescription is valid for one year. All patients are required by law to come in for annual contact lens evaluations and corneal evaluations before a contact lens prescription can be issued. This is necessary to ensure the patient’s eyes are healthy and the contacts are fitting well.
Contact lens prescription fees vary based on how complicated the evaluation will be. First time soft contact lens wearers can expect contacts lens fees to start at $65.
The consult fee for established soft contact lens wearers ranges from $45-$85 based upon the complexity of the evaluation.
Contact lens evaluations are a separate charge and NOT covered by your routine vision or medical insurance.
Cancellation/No Show Policy
Eyes on Evesham, LLC, requires a 24-hour notice for ALL cancellations. By scheduling and confirming this appointment you are agreeing to our cancellation policy both as a new and established patient for all future visits. There may be a fee assessed which is not covered by insurance and would be an out-of-pocket expense for cancellations without proper notice. If a cancellation is unavoidable, we do ask that you give us as much notice as possible so we may offer that appointment time to another patient.