Dear Insurance Patient:

Insurance companies have informed us that we must separate the part of your eye examination that is called the “refraction” from the medical part of the examination. The refraction is that part of the eye exam that determines your need for glasses or contacts.

As this is considered non-medical and as insurance may not pay for “wellness” or “routine care”, it may not be payable by the insurance system. Therefore, your responsibility for this refraction portion of the examination (when performed) is $40.00.

Since we do participate with insurance, the medical portion of your examination should be covered. Any necessary co-pays will be required. Should you have any questions regarding these issues, please feel free to ask any of our staff when you come in for your appointment.

We appreciate your cooperation with this matter.

Instructions:

1. Please complete our New Patient Information Form first.
2. Enter the patient's Social Security Number.
3. Select the appropriate option(s) below.
4. Select "Submit."