Medical And Vision Insurance Information Form (Page 4 of 4) in pdf

Tuscaloosa Ophthalmology, P.C.

A. George Kudirka, M.D. ♦ E. Van Johnson, M. D.

Riverside Medical Center Suite B-1 ♦ 535 Jack Warner Pkwy. NE ♦ Tuscaloosa, AL 35404

(205) 556-2121

CONTACT LENSES POLICY

It is our policy that all contact lens patients fitted by our doctors purchase one set of contacts from our

optical shop to ensure that the fit of the contacts prescribed is correct. Please let the nurse know if you are

interested in contact lenses prior to the exam. If there are any questions, ask the nurse at that time. There

will be an additional fitting fee charged for contact lens exams, which involves the additional services and

time necessary to properly fit and examine the contact lenses prescribed by our doctors. These charges

include a comprehensive eye exam by a board certified medical doctor, prescription for glasses, contact

lenses examination, contact lenses training by our optical technician and fit evaluation by the doctor.

• If you have insurance with vision coverage, the insurance must be an approved plan and be

verified before you are seen.

• Contact lens patients must have an exam every 12 months. These appointments should be made at

least 6 weeks in advance to help insure an appointment is available before the prescription expires.

I have read and understand this contact lenses policy. ________(Initials)

Routine Vision Charges Review

Established

New

(Fitted by our Doctors in the last 3 years)

Comprehensive Exam

$80.00

Refraction Fee

25.00**

(Not covered by Medicare)

Contact Lenses Exam

15.00

29.00**

**These charges may only be covered by your insurance if you have vision coverage. Contact lenses exams

are performed at the patient’s request, but refractions are necessary to determine any change in prescription,

whether it is for glasses or contacts.

Note: Your insurance may cover your exam even if you do not have vision coverage, but refractions and

contact lenses exams are covered only on plans specifying these charges under a vision policy.

I understand that I am responsible for any charges not covered by my insurance policy the

day of the visit, including co-pays, co-insurances, and non-covered services.

Signature: ____________________________________

Date: ________________________

Medical And Vision Insurance Information Form Page 4