Contact lens fees contact lens evaluation fee
|
|  Yüklə 49 Kb.
|
Office phone numbers: North (317) 844-6269 South (317) 887-7777 Castleton (317) 598-2020 Fax (317) 815-7567 After Hours (317) 631-3466 Earl E. Lanter MD James E. Wilson OD, FAAO Donald H. Hulsey OD Allison L. Nowak, OD, FAAO CONTACT LENS FEES CONTACT LENS EVALUATION FEE At the time of your initial visit, if you are wearing contact lenses, additional evaluation is required to properly assess your present contact lenses and the eyes’ response to them. If you are not wearing lenses, this evaluation will determine your ability to successfully wear contact lenses. This evaluation allows the doctor to determine if there are any current problems and/or potential risks associated with the wear of your contact lenses. This fee of $40.00 may not be covered by your basic examination insurance plan. CONTACT LENS MANAGEMENT FEE This is an additional fee that may be required, upon your approval, to replace, refit or fit your contact lenses. This fee will cover all office visits and lens changes for three months to assure that we have provided you with the best possible lens performance and ocular health. The charges range between $65 - $400 (excluding VST lens). These charges are dependent upon the complexity of your visual condition. This fee will be discussed with you at the end of your visit. These charges do not apply if you are an existing patient and we are duplicating your present lenses. If the lenses are being fitted for a medical reason, these fees may be partially covered by your medical insurance; otherwise, your basic vision plan may not cover this fee. CONTACT LENS MATERIAL The charge for your contact lenses will vary depending upon the lens type. A typical standard soft disposable contact lens supply of a one month replacement lens for one year is $96. A standard rigid gas permeable contact lens design is $150 per pair. If you are not sure if your insurance will cover these fees, please contact your insurance carrier. I have read the above and understand that I am only obligated for the $40.00 evaluation fee. Any additional fees will be subject to my approval before proceeding with any refitting or fitting. ____________________________________ __________________ Signature Date ___________________________________________ Printed Name REVISED 09 2007 FORM #106 |