ALL EYECARE OPTOMETRY

277 HAMPSHIRE ROAD

THOUSAND OAKS, CA 91361

(805)495-4625

What is a refraction?

Refraction is a measurement taken by an eye doctor to determine whether a patient has nearsightedness (myopia), farsightedness (hyperopia), or astigmatism. Based on the results of the refraction, the doctor decides whether or not to prescribe glasses. A refraction can be accurately performed on a patient of any age, with or without his or her input. For the majority of patients, refraction is a critical component of an eye examination.

Will your insurance pay for a refraction?

Even though this is a vital test in the care of your eyes, the refraction is a non-covered benefit with most insurance plans. Unfortunately, they do not differentiate between “medical refractions” and refractions performed for the purpose of providing glasses or contact lenses. We are required to charge for this service regardless of whether your insurance company will cover the service as a benefit of your insurance plan.

There is a fee of $40.00 ($35.00 if paid at the time of the visit) for this test. You will be asked to pay at the time of your visit. This fee will be charged to you approximately one time per year. This is a routine charge at all medical, optometric and surgical ophthalmology practices.

_____ I understand that a refraction is a non-covered service and request an updated prescription and evaluation to properly assess my best corrected vision.

Retinal Examination:

Our Doctors are concerned about retinal diseases such as macular degeneration, glaucoma, retinal detachments, and diabetic retinopathy; all which can lead to partial loss of vision or blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be detected with a retinal examination. Eye exams with retinal evaluations can help you safeguard both your eyesight and general health.The Optomap Digital Retinal Imaging allows us to thoroughly evaluate your internal eye health with dramatically improved precision that includes a depth in the retina not seen with regular dilation.

With an annual Optomap, our doctors can track your eye health for concerns, comparison, and treatments. Because Medical and Vision insurances do not pay for routine photos, there is a $35.00 fee for this procedure. (Please advise staff if you have a history of epilepsy.)

The Optomap augments a dilated exam by creating a permanent documentation of the interior retina.

_____ I elect to have an Optomap Digital Retinal Scan of my retina and understand the scan will provide a permanent baseline comparison for my future visits. I understand that based on the doctor's examination a dilation may still be recommended or necessary.

_____ I DECLINE the Optomap Retinal Scan and am choosing to only be dilated today. I understand that my vision will be slightly blurry after dilation and light sensitive for 3-4 hours.

I understand I am responsible for any fees associated with medical services which may be non-covered benefits.

Print Name: ______Signature ______Date:______

Understanding Your VisionBenefits

Let’s face it, insurance can be confusing. This is particularly true when an individual has both medical andvisioncoverage.UnderstandingyourinsurancePRIORtoanyservicecanhelpyouavoidconfusion andfrustration.

VISIONINSURANCE is one of the mostmisunderstoodbenefits of all health-relatedcoverage.Someinsurance companies do a better job of educating their clients than others. At times insurance companies’ “customer service” departments overstate benefits (and minimize or even ignore specific limits and restrictions) that can create an adversarial relationship between the patient and the doctor’s office.Wewouldliketoavoidthesemisconceptions,andwehopethatthefollowingwillhelpyoubetter understand how vision coverageworks.

Medical vs.Vision

MedicalinsuranceDOESNOT cover vision relatedissues such as routineexams, glasses, and contactlenses. Many people with medical insurance have a separate rider policy to cover routine eye exams. Most vision plans to do not cover ANY medical testing, diagnosis, consultation or treatment. Vision insurance covers ONLY routine eye exams for purchasing glasses or fitting and purchasing contact lenses. Regardless of your vision insurance, most plans do not cover 100% of expenses, and thus you should expect some out-of-pocket costs. Theremay be co-pays,deductibles or a percentage of costs that you will pay out-of-pocketas required by yourinsurancepolicy. As with mostdoctors, at Children’sEye Care the patient’s portion must be paid before materials (glasses or contacts lens) can be ordered. And all co-paysare due at the time services arerendered.

MEDICAL concerns (Glaucoma, Dry Eyes, Macular Degeneration, Red-Eyes, Floaters, Allergic Conjunctivitis) take priority and as such will be treated first or concurrently with a vision problem. Sometimes a medical condition has to be treated and corrected before vision can be accurately evaluated. Medical insurance companies usually separate the components of an eye exam, one being the comprehensive exam and theotherbeingtherefraction.(Therefractiondeterminestheprescriptionforeyeglassesandcontacts.) Typically, VISION insurance policies usually cover both the ROUTINE EXAM and REFRACTION, while MEDICAL policies cover the EXAM only. You are responsible for the cost of the refraction if your insurance is medicalonly. If the presence of disease is detected that require additional testing, the doctor will provide you information regarding the condition and the testing required.

Billing Practices:

Your medical insurance will be billed for any additional necessary testing and you will be responsible for any deductibles or payments as contracted by your insurance company. Payment of those services are due within 60 days of the response from your insurance company in the form of their Eligibility of Benefits (EOB's). Failure to contact the office or attempts to make payment within the allotted window will result in your account being sent to Transworld Collection Agency.______(Initial)

InSummary

Although our staff members are very knowledgeable about insurance plans, remember that it is not the doctor’s or staff’s responsibility to know the details of your individual plan. It is to your benefit to be aware of possible deductibles and co-pays that are part of yourplan.Yourinsurance plan maycoverroutine vision care, but if your deductible has not yet been met, you will still have to pay for the service until your deductible is met. Your insurance is a contract between you, your employer and the insurancecompany; not with thedoctor. WeencourageyoutospeakwithyourinsurancecompanyPRIORtoyourappointmentaboutyourplansspecific details. Then, as always, feel free to ask us questions about how they will apply to your upcoming visit. We will do everything we can to help you better understand your policy, but the more knowledgeyouhaveabouthowitworksaheadoftime,thelessfrustratingitwillbeforyouatthetimeof theexam.