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REFRACTION POLICY, HIPPA

  • One of the most important parts of your eye exam is the refraction. That is the part of the exam by which we determine whether you can be helped in any way by a new glasses prescription. It is also how we determine the best possible visual acuity and function of your eyes, which is essential medical information for us as we assess your eyes and look for problems. It is NOT a covered service by Medicare and many other insurance plans. These plans consider refraction a "vision" service, not a "medical" service. Our office fee for refraction is $35.00 and unless your plan automatically covers the refraction charge, this fee is collected at the time of service in addition to any co-payment your plan may require. If you choose not to have a refraction, please notify the front desk staff prior to the exam.

    One of the most important parts of your eye exam is the refraction. That is the part of the exam by which we determine whether you can be helped in any way by a new glasses prescription. It is also how we determine the best possible visual acuity and function of your eyes, which is essential medical information for us as we assess your eyes and look for problems. It is NOT a covered service by Medicare and many other insurance plans. These plans consider refraction a "vision" service, not a "medical" service. Our office fee for refraction is $35.00 and unless your plan automatically covers the refraction charge, this fee is collected at the time of service in addition to any co-payment your plan may require. If you choose not to have a refraction, please notify the front desk staff prior to the exam.

  • RETURNED CHECK FEE

  • I also understand there will be a $30.00 return check fee for all returned checks.
  • Date Format: MM slash DD slash YYYY
  • PATIENT PRIVACY INFORMED CONSENT (HIPAA)

    I have been informed, and I consent to the release of my medical information, in compliance with federal HIPAA regulations. My medical information will only be released to other medical providers for continuity of care and insurance companies in order to get my medical claims reimbursed. I do understand that my patient information and diagnosis will be forwarded to these entities to facilitate continuity of care, and to get claims paid. Bowers Optometry, PA practices a minimum information disclosure policy, and only necessary information will be forwarded to these entities. I understand that Bowers Optometry, PA reserves the right to change their privacy notice and make changes effective for all personal health information they may already have concerning me. If any changes occur, Bowers Optometry, PA has agreed to provide me with a revised copy upon my request. I authorize Bowers Optometry, PA and Kimberly L. Bowers, O.D. and her staff to release my health information for these purposes.
  • Date Format: MM slash DD slash YYYY
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