"I request that payment of benefits be made to me or the doctor for any services provided. I also authorize any holder of medical information about me to release to the carrier and its agents any information needed to determine these benefits or the benefits payable for related services."

"I understand that any services not covered by insurance and co-pays are due at time of service."

"I also acknowledge that I will have an opportunity to receive a copy of the Privacy Practices and Policies of this practice."

The iWellness scan is a quick, non-invasive scan that allows the doctor to see beneath the surface of your retina. This unique technology can help our doctors detect vision threatening and systemic diseases in their very early stages, when they are most treatable. Vision threatening diseases such as glaucoma, macular degeneration, and diabetic retinopathy often have no signs or symptoms in the early stages. Our doctors recommend that ALL patients have this procedure performed, and it is especially important for people who have a personal or a family history of glaucoma, macular degeneration, or other eye diseases. It is painless and there are no side effects or light sensitivity. Any questions that you may have about your iWellness scan and the results of the scan, can be discussed with the doctor during your examination. The scan is part of your medical record and can be compared with future scans, allowing us to observe even the smallest amount of change. There is a $45 charge for this test and it is not covered by your vision plan or medical insurance. Thank you for choosing our practice to protect the health of your eyes!

I authorize the release of information including the diagnosis, records, examination rendered to me and financial information. This information may be released to:

This Release of Information will remain in effect until terminated by me in writing.

Messages

Please complete if you are interested in wearing or renewing your contact lens prescription.

All previous and new contact lens wearers require a yearly contact lens evaluation. This evaluation will help us to determine if your eyes are healthy enough to be fit with contact lenses or to continue wearing contact lenses. There are many factors involved in evaluating the health of your eyes for contacts. Even comfortable happy contact lens patients can suffer from complications that are unknown to them.

• The evaluation fees include all visits related to contact lenses and all diagnostic lenses for a period of 60 days. Any visits beyond the fitting period may require an additional fee.
• Yearly eye health examination, vision evaluation and contact lens evaluation will be required to refill contact lens prescriptions.

Expected Charges:

Initial Fitting

• Eye Health and Vision Examination - Cost Based on Insurance
• Diagnostic Contact Lens Fitting - $150-$500 (Cost depends on the complexity of the diagnostic contact lens fitting)
• Insertion, removal, handling and care instructions - $40

Annual Evaluation

• Eye Health and Vision Examination - Cost Based on Insurance
• Contact Lens Evaluation - $150

* We will apply any possible insurance benefits to your contact lens fitting
* All contact lens evaluation and fitting fees are non-refundable.

I understand that the contact lens prescription will be valid for one year and that an annual eye health and contact lens examination will be required to update this prescription. I understand that wearing my contact lenses for more than the prescribed time or improper care increases my risk of infection, discomfort and poor lens performance.

I understand that contact lens fitting and evaluation fees are separate from and in addition to comprehensive exam fees. Most insurances do not cover contact lens fittings, but some may give an allowance toward materials. Fees are due at time of service.