In most cases, contact lenses are not considered "medically necessary" by insurance companies. Any costs performed to determine or update a contact lens prescription may not be covered by most insurance companies and will be the responsibility of the patient.

I, the undersigned, authorize payment from my insurance company to be made to Fowle Eyecare Associates PLC, for covered services. I understand that I am responsible for obtaining any referrals I beforeorinfullforthatvisit.Regardlessof must appointmentinsurancestatus,am necessarymypaymy ultimately responsible for the balance on my account.

Should timely payments of this account not be made, I authorize Fowle Eyecare Associates, PLC, to retain theservicesofanand/orcollectiontoassistwiththecollectionofbalance. outstanding attorney agencyany Any expenses incurred by such action shall become my responsibility.

I certify that the information I have provided with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled.

This authorization may be revoked by myself at any time in writing.

OCT technology is a new, state-of-the-art way to analyze and document the optic nerve and retina inside the eye. This quick, painless scan can give the doctor
additional insights into eye diseases such as glaucoma, diabetes, macular
degeneration and more.

This "iWellness" test allows for earlier detection of these potentially sight­
threatening conditions and offers information the doctor was previously unable to see with conventional techniques. This test, however, is not included in your vision or medical plan, and as a result, a $39.00 fee will be your responsibility for this enhanced level of service. For patients newly or previously diagnosed with related ocular conditions, the test can then be billed to medical insurance plans.

The doctors at our office recommend the iWellness scan be performed on all adult patients.

For questions on the scan please ask an/Fowle Eyecare staff
member and they will be happy to assist you.

For the safety of all and to help stop the spread of COVID-19:

While in the office, please maintain a safe distance between you and others of at least six feet and avoid touching surfaces and your face. Thank you for helping us keep everyone safe and healthy.

I have fully informed these health care providers of my entire medical condition so that they can exercise their professional judgment regarding my care.