NOTICE OF PRIVACY PRACTICES, AUTHORIZATION TO RELEASE INFORMATION TO INSURANCE COMPANY, & ACKNOWLEDGEMENT OF RESPONSIBILITY FOR PAYMENT, CONTACT LENS AND GLASSES AGREEMENT
I understand that Bauer Eyecare is a healthcare provider and may share my health information for treatment, payment, and healthcare operations. I hereby assign all medical benefits (to which I am entitled) to the doctor caring for me. Bauer Eyecare will file insurance coverage for me if I provide them with a copy of my current insurance card on the same day of my appointment. This includes any health plans in which I am enrolled. This assignment will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not they are paid by my insurance; I understand that benefits quoted by my insurance to your staff are NOT a guarantee of payment. I hereby authorize the holder of my medical and patient registration records to release any information needed to process my insurance claims. I understand that I am the guarantor of this account. We bill participating insurance companies as a courtesy to you. You are expected to pay your deductible and co- payments at the time of service. If we have not received payment from your insurance company within 60 days of the date of service, you will be expected to pay your balance in full.
There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both:
1. Vision care plans (such as VSP and EyeMed)
2. Medical insurance (such as Aetna and Medicare).
• VISION CARE PLANS only cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.
• MEDICAL INSURANCE must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history. (Such Diabetes, High Blood Pressure complications, Macular Degeneration, Cataracts, Glaucoma, etc.)
• If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense. *If you have not reached your deductible or your insurance determines that the payment is your responsibility, you will receive a bill.
A copy of my medical records can be requested in writing and will be provided to me or whomever I designate for $15.00. I do acknowledge that there is a $25.00 fee for returned checks. I am aware that if I do not have insurance coverage, I will be responsible for payment. Payment is due at the time of service. All patient balances are due at the time of service unless a formal payment plan is established with the clinic. A $25 per month billing fee will be assessed for any balance over 60 days.
PATIENTS UNDER 18 years of age: Cannot come alone to their appointment, if they do, parents are responsible to contact the office and get a detail of their encounter and also pay for any services rendered and/or product(s) ordered.
MISSED APPOINTMENTS/LATE CANCELLATIONS
Broken appointments represent a cost to us. Cancellations are required 24 hours prior to the appointment. Excessive abuse of scheduled appointments may result in discharge from the practice. A $50 fee will be charged for missed or late-cancellation appointments.
"By signing I acknowledge that I have read, understand and agree to this financial policy and authorize assignment of payment directly to Bauer Eyecare for services provided to me. I also authorize the release of pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
INFORMED CONSENT FOR DILATION OF EYES
The purpose of dilating your pupils is to perform a thorough examination of the health of your retina by viewing around the iris. This allows the doctor to access the peripheral retina, an area which would normally be blocked. Individuals with diabetes, glaucoma, high prescriptions, systemic disease, and those over 40 years old or have never been dilated before it is strongly encouraged to have this procedure. However, certain side effects may occur. These include blurry vision, light sensitivity, nausea, dry mouth, and burning upon the installation of drops. These effects can last for 6-8 hours. If you should experience the above-mentioned symptoms including decreased vision, halos around lights, foggy vision, brow/ headache, redness, or pain lasting longer than 6 hours call or return to our practice immediately.
OPTOMAP (OPTOS) RETINAL IMAGING
Our doctor strongly recommends having Optomap retinal imaging. The Optomap can provide an ultra-widefield 200-degree retinal image. While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough exam of the retina is critical to verify that the back of the eye is healthy. It can lead to early detection of common diseases, such as glaucoma, diabetes, high blood pressure, macular degeneration, bleeding in the retina, detection of any holes, tears, detachments or even cancer. This test is quick, painless, and does NOT require dilation drops. (Please advise staff if you have a history of epilepsy.)
OCT RETINAL SCAN
The OCT retinal exam is a technology that lets the doctor see beneath the surface of your retina in 3D, where signs of disease first appear. Traditional eye exams and retinal photography do not provide this level of detail. This instrument operates using optical coherence tomography to evaluate the optic nerve for diseases such as glaucoma or optic neuritis. It also evaluates for problems and diseases in the macula such as macular degeneration, diabetic retinopathy or macular holes.
If you would like the OCT screening alone for $29 (Good)
If you would like the Optos screening alone for $39 (Better)
If you would like the Optos screening and OCT for $49 (Best)
If you would like to have DRE (Dilated Retinal Exam) $0
If you would like to decline both Optomap, OCT, and DRE (see below)
I understand that the potential for partial or total loss of vision may exist due to undetected eye disease. I therefore release Bauer Eyecare and associates from any liability resulting from failure to diagnose or treat any eye condition due to the lack of diagnostic information, which could have been obtained by performing these tests.
CONTACT LENS AGREEMENT
First time Contact Lens patients require the following: Contact Lens evaluation, fitting and training
Current Contact Lens patients require the following: Contact Lens evaluation and fitting
Contact Lens evaluation & Contact Lens fitting:
Every year, each patient that wears Contact Lenses must be evaluated for any ocular health changes and changes to their vision and Contact Lens prescriptions. There is a fee each year dependent on your lens type and the measurement of your prescription. There are 3 levels of evaluation & fittings - Level 1, Level 2 and Level 3.
Contact Lens evaluation/fit fee: (Cash Price or non-covered insurance price)
Level 1: (Single Vision): $85
Level 2: (Multifocal & Toric): $110 (MonVision / Astigmatism)
Level 3: (RGP) & Soft XR: $150 (Multifocal / Astigmatism)
* Medicaid covers contact lens fitting for patients under 21 years of age. Exclusions apply.
Contact Lens Training:
Only applies to first time Contact Lens (CL) wearers and is to be completed to the satisfaction of the doctor. The fees for Contact Lens Training include 3 sessions for the patient to learn how to wear Contact Lenses; if at that time the patient fails to insert contact lenses successfully the contact lens evaluation will be terminated and the contact lens evaluation fee will not be returned and it will be used to pay for staff time.
Contact Lens Follow Up:
All Contact Lens follow ups are included within your Contact Lens evaluation fee. The Contact lens follow up is at no extra charge if it is scheduled within a month and only necessary if the doctor recommends it. Your contact lens evaluation includes a follow-up appointment within 60 days of your initial visit. It is your responsibility to keep your follow-up appointment. It is a must that you wear your trial contacts when you come in for your visit. If your follow-up is more than 90 days after your initial visit the following fees will apply:
> 90 days - 6 months: $40
More than 6 months: (Evaluation + Refraction*)
Contact Lens Evaluation:
If you have already had your eye exam at Bauer Eyecare and need a contact lens evaluation:
If your contact evaluation is more than 90 days after your initial visit the following fees will apply:
0 to 90 days: CL evaluation fee
90 days to 12 months: (Evaluation + Refraction*)
Outside Rx Contact Lens Evaluation:
A Contact Lens fitting only (without exam) will require a Refraction fee even if you have an outside glasses Rx:
Your contact lens exam evaluation includes a follow-up appointment within 90 days of your initial visit. It is your responsibility to keep your follow-up appointment. It is a must that you wear your trial contacts when you come in for your visit. If your follow-up is more than 90 days after your initial visit the following fees will apply:
0-90 days (Contact lens evaluation + Refraction)
> 90 days - 6 months: $40
More than 6 months: (Evaluation + Refraction*)
*Refraction will be determined by your doctor
At Bauer Eyecare, your satisfaction is our goal and we realize that dissatisfaction usually occurs when expectations are not met. We will stand behind everything that we do and want to thank you for putting your trust in us!
Lenses will be warranted against scratches only if a scratch coating or non-glare treatment is purchased. Warranty covers a 1 time replacement for scratches and defects for 2 years. Mirrors have 1 time replacement for scratches in 1 year.
Neurolenses will be warranted against scratches only if a scratch coating or non-glare treatment is purchased. Neurolenses will be warranted for scratches 1 time per year for 2 years. If you are unable to adapted to your Neurolenses successfully, we will be happy to change you to an alternate lens option.
Warranty lenses will be made with same prescription and treatments only.
Manufacturer lens logos (example: Oakley, RayBan) are not included unless patients request it and it is paid for a head of time (Vision Plans will not pay for it). If patients request a tint to be matched it is not guaranteed that it be an exact match, our lab will get it as close as it can.
Frames will be warranted for 1 year against manufacturer defects only. ALL parts must be returned for warranty. * There will be a fee to cover shipping. Do not modify or glue a broken frame as this will void manufacture warranty. (This is a vendor policy not ours)
Changes in prescription, material or type of multifocal can be remade 1 time only within 60 days of the original order at no charge to you, unless you request an upgrade. If you have issues after 60 days of picking up your new glasses a remake fee (lab specific fee) and refraction will be charged. Redos are intended to replace lenses only and do not allow for frames changes. If you are having issues with your glasses after 6 months a new exam will be needed and standard exam fees apply. If you did not receive your Rx from Bauer Eyecare you will need to return to where you were provided your prescription for a prescription verification (Rx Check) before 60 days or pay for a refraction fee here.
PATIENT’S OWN FRAME
If a patient request Bauer Eyecare put new prescription lenses into their existing frame, Bauer Eyecare will not be held responsible if the frame should get lost, cracked, chipped, scratched or break in the lens process. If this does occur, the patient may incur additional costs.
PROGRESSIVE LENS ACCEPTANCE AGREEMENT
These lenses are the closest lenses available to your natural vision, helping you to see at all distances. We want you to be completely satisfied with these lenses but we need your help to do so by following these guidelines:
You need to wear the progressive lenses for at least 2 weeks
Return for adjustments when having difficulty using the progressive lenses
If you are unable to use your progressive lenses successfully, we will be happy to change to an alternate lens option with no additional charges. However, NO REFUND WILL OCCUR.
LENS SAFETY: I have had the benefits of impact resistant Polycarbonate and/or Trivex material explained to me.
DELIVERY TIME: I understand delivery time is subject to many variables and that product may not arrive by the estimated time. We will do our best to notify you if there are delays.
ORDER AGREEMENT: I accept this order as written. Because your prescription is unique to you, ALL SALES ARE FINAL, NO REFUND ON LENSES OR FRAMES, once this order has been placed. All orders will be placed on the same day you authorize payment. Make sure all insurance benefits have been presented. Insurance claims cannot be filed after the order has been placed. PD is not included on the eyeglass prescription (not require by the State of Colorado), measuring it will have an extra charge of $20.
2nd PAIR DISCOUNT: I have had the 2nd pair discount explained to me and the offer is valid for 60 days. Discount will be 40%.
ADJUSMENTS: If I request for an adjustment on my frame, Bauer Eyecare is not responsible for possible damage or breakage on frame or lenses.