Patient Check In

We are so happy to see you as our patient. Please complete this form before you arrive for your appointment. In order to maintain the best timely care for each of our scheduled patients, we are adhering to a strict 10 minute late policy. If you arrive more than 10 min past your scheduled appointment time, we will help you reschedule your visit with us. We are so grateful for your understanding.

HIPAA Compliance and Financial Responsibility Consent for Form Acknowledgement

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).
  • Obtaining payment from third party payers (e.g. my insurance company).
  • The day-to-day healthcare operations of your practice. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Contact Lens Fitting Fees & Training Consent

Contact lenses are considered by insurance companies as a cosmetic, non- essential visual option for most patients. Therefore, the contact lens portion of your exam is not covered by most routine eye exam visits, and will incur a separate fitting, dispense and material fees, that is in addition to your routine exam co-pays.
Any contact lens benefit you may have typically covers only a small portion of the costs of owning and purchasing contact lenses. These contact lens fitting and assessment fees are usual and customary at any eye care facility and are due upon check out if you receive contact lenses today.
Typical contact lens fitting, dispense and follow up fees range from $119- $299+, depending on the complexity of the fit and materials involved. Some contact lens fits may be greater in price if deemed specialty fit as determined by your prescription and eye health.
Contact lenses are not deemed medically necessary by insurance as they are a cosmetic choice the patient makes, therefore insurance does not cover this cost. If you are a new contact lens fit, insertion and removal training is necessary for your safety and you will be charged $29 for each 30-45 min training session. You cannot take your contact lenses home unless you can demonstrate proficiency and safety in inserting and removing your contact lenses at your visit and approved by our doctor after evaluation.