Click here - Contact Lens Institute

Document Sample
Click here - Contact Lens Institute Powered By Docstoc
					                                CONTACT LENS INSTITUTE
                                 PAYMENT AGREEMENT


Insurance plans generally cover a routine eyeglass exam only. This exam includes a medical
history, external exam(for example: evaluation of pupils, extraocular muscle balance and motility,
screening visual fields), glaucoma check, eyeglass refraction(to determine your glasses
prescription), biomicroscopy(for example: evaluation of cornea, lid, conjunctiva, lens, iris), and
ophthalmoscopy(for example: evaluation of optic nerve and retina).

Your insurance plan may not cover photographs, corneal topography, or dilation. It may be
necessary to perform one or more of these tests to complete your exam and/or to evaluate you
most thoroughly. In this case, you will be responsible for payment of these services.

If you wear contact lenses or wish to try contact lenses, your insurance plan does not cover
the contact lens portion of your exam ie the fees associated with the fitting and evaluation of
your contact lenses is not a covered benefit under your insurance plan. Therefore, you will be
responsible for payment of these services.


I understand the above services are not covered by my insurance plan. I will be financially
responsible for payment of these services.




_________________________________________                   ________________________
          Patient Signature                                         Date

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:1
posted:6/22/2011
language:English
pages:1