ACKNOWLEDGMENT OF COMPREHENSIVE EYE HEALTH EXAMINATION & INSURANCE BILLING POLICY

At Eye Rx, our doctors provide comprehensive eye health examinations that go beyond a routine vision screening. This means they evaluate and monitor for medical conditions that may affect your long-term eye health.

Because of this, we request both vision and medical insurance when available. Your visit may be billed to your medical insurance instead of your vision plan if a medical condition is diagnosed or monitored during your exam.

Vision vs. Medical Insurance

✔ Vision Insurance covers routine eye exams for prescriptions (glasses/contact lenses) and basic screenings.

✔ Medical Insurance covers exams and testing for eye diseases or conditions, such as:

Glaucoma / Glaucoma Suspect
Macular Degeneration
Dry Eye Syndrome / MGD
Diabetic Retinopathy
Cataracts

Additional Testing & Follow-Ups

If a medical condition is detected, additional tests such as Optos Retinal Imaging, OCT Scans, or Visual Field Testing may be required. These tests, along with any follow-up visits, may also be billed through your medical insurance, and co-pays, deductibles, or co-insurance may apply.

Patient Acknowledgment

By signing below, I acknowledge that:

Acknowledgment Statements *

My exam today may be billed through medical insurance if a medical condition is found.

Additional tests and follow-up visits may be required for monitoring and will also be billed through medical insurance.

I am responsible for any applicable co-pays, deductibles, or co-insurance under my medical plan.

I had the opportunity to ask questions about this policy before my exam.

Please check all boxes to acknowledge your understanding

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Patient Signature *

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