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 necessary before my appointment or I must pay in full for that visit. Regardless of my insurance status, I am 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 ofwith and/orthe servicescollection theanattorneycollectiontoassistofoutstandingbalance. 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.

              ****** A NOTE TO ALL OUR CONTACT LENS WEARERS ******

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. Please list the person financially responsible for this

** No Show Policy** - out of respect to others who want to schedule with our Doctors, not showing for a scheduled appointment will incur a charge of $50

The Optomap retinal imaging is fast, easy, and comfortable. It may alleviate the need for dilation and provides a permanent record for annual review. The Optomap scan gives a panoramic image of your retina. These images help the doctor assess the health of your eyes and potentially detect other serious health problems such as diabetes, hypertension, heart disease, cancer, and auto-immune disorders. Early detection could help save your vision or your life!

The cost of the Optomap imaging is $35

OCT technology is a 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 unrivalled detail into eye diseases such as glaucoma, diabetes, macular degeneration and more. The OCT “iWellness” test allows for earlier detection of these potentially sight-threatening conditions and offers information the doctors are unable to see with conventional techniques. OCT is for 18yo+ only.

The cost of the OCT test is $35

Currently these next-level screening techniques are not covered by medical or vision plans but are strongly encouraged by our doctors to ensure the best possible care. Because we feel they are so important, we are offering both tests at a discounted price of $50 total for Optomap and the OCT.