Patient Information
FTC’s Eyeglass Rule and Contact lens Rule
It is required that your eye doctor provide you with a copy of your eyeglass prescription after a refractive exam is completed. Please note, not all exams are considered “refractive exams.” A copy of your eyeglass prescription will be provided at the end of your exam if a refraction is performed. You are in no way obligated to purchase your glasses in order to receive the prescription.
Included below is important information to review prior to receiving your contact lens prescription.
The Center for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free. Especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment."
The CDC recommends the following for contact lens wearers:
-Schedule a visit with your eye doctor at least once a year.
-Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision. -Understand that eye infections that go untreated can lead to eye damage or even blindness. The Food and
Drug Administration (FDA) indicates:
- "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional."
Sign below to acknowledge and consent that you will be provided in the patient portal with an electronic copy of your eyeglass prescription and (if applicable) contact lens prescription at the completion of your contact lens fitting. A paper copy can also be printed at the end of your exam if requested.
Acknowledgement of Pupil Dilation
I understand that Florida Board of Optometry requires optometrists to perform a dilated exam of the retina during the patient’s comprehensive exam. I understand that the optometrist recommends it to evaluate the internal health of my eyes more thoroughly. Please indicate your preference:
OCT Retinal Exam
The Ocular Coherence Tomographer, also known as the OCT Retinal Exam, is a scanning digital image of the retina, macula, and optic nerve. It allows the Doctor to better diagnose, treat, and follow changes to the retina over time. The OCT Retinal Exam can be billed to some insurance carriers, while other carriers recognize it as a “non-covered service,” meaning the patient will be responsible for the charges. Dr. Brad and Ashley Masuga highly recommend this imaging for all patients once a year. The out-of-pocket fee for the retinal imaging exam is: $49.00
****PLEASE NOTE: Payment is required at the time of service***
I certify that the information I provided is correct. I authorize the release of medical information necessary to process insurance claims to Medicare or any other insurance company. I authorize payment of medical payments to InFocus Family Eyecare for any services rendered to me by any doctors of InFocus Family Eyecare.
I understand that my insurance is a contract between my insurer and myself. I am responsible for understanding the terms of my policy, including deductibles, co-pays, co-insurance, and referrals. I am responsible for obtaining any required referrals, and in absence as such, I will be held responsible for the cost of services provided.
I acknowledge that I received a copy of InFocus Family Eyecare’s Notice of Privacy Practices (HIPAA).
Medical Insurance - Explanation of Coverage
About Your Insurance
There are two types of health insurance that will help cover eye care services and optical products; you may have both types. InFocus Family Eyecare accepts most medical insurance plans such as Medicare, Blue Cross/Blue Shield, Aetna, United Health Care etc. InFocus Family Eyecare is out-of-network with vision plans such as VSP, Eyemed and Spectera.
Medical insurance must be used for medical eye care involving the diagnosis, management, and treatment of eye health conditions such as diabetes, dry eye, glaucoma, cataracts, eye infections, etc. Depending on the insurance plan, patients will be responsible for their deductibles, co-pays, and non-covered services as allowed by the insurance contract.
Vision Plans may contribute toward routine visits and eyewear products such as glasses and contact lenses. They do not cover medical eye care. If you have both types of insurance, you may be able to use your medical insurance towards your exam services, and your out-of-network vision benefits towards your eyewear and/or contact lenses. If your vision plan has out-of-network benefits, we will discuss your coverage options and coordinate benefits in order to reduce any out-of-pocket patient expense.
Fees that are not paid by your insurance will be billed to the patient. As a reminder, health insurances do not cover all procedures; even some that your health care provider may feel are necessary for you. Please ensure you understand your insurance coverage so that you can make an informed decision about your care.
Refraction Fee
A refraction is a portion of the exam that evaluates a patient’s vision and determines if a vision correction is needed to improve sight. When using your medical insurance, the refraction is considered a “non-covered service” and will be billed directly to the patient. The refraction fee is $45.00.
Out of Network Plans
Patients who have an out-of-network vision plan or medical plan may be able to use their benefits for exam services and eyewear materials. Patients will be required to pay for any services and materials they receive during their visit. For the convenience of the patient, InFocus Family Eyecare will then bill the vision or healthcare insurance provider. Once the claim has been processed by the insurance company, the patient will receive a reimbursement check in the mail.
We ask all patients to please provide our team with insurance cards for both medical and vision plans. This will allow us to bill the appropriate carrier and reduce any out-of-pocket costs. We are required to have your medical insurance and/or Medicare Card on file for future billings to your insurance. We will always notify you for approval before we bill any insurance plan.
Signing below indicates that you understand this notice and agree to the terms:
