Please Read and Sign if Interested in Contact Lenses
Professional Standards of Care require that all people who wear contact lenses have a full comprehensive exam and contact lens evaluation at least once every year. This form is intended to make clear any misconceptions concerning the professional services and material costs of contact lenses. Your vision benefits may not cover, or may only cover a portion of, the charges for a contact lens evaluation. Please read carefully and sign at the bottom:
- We will not dispense contact lenses or write a contact lens prescription without a comprehensive eye exam and contact lens evaluation, including all necessary follow-up visits, each and every year.
- A comprehensive eye exam consists of tests which include:
- Determination of the refractive status of your eyes (myopia, hyperopia, astigmatism, presbyopia.)
- Evaluation of ocular tissues, internally and externally, and any diagnosis of diseases or disorders relating to the eye.
- Assessment of the functional ability of the visual system.
A CONTACT LENS EVALUATION must be done IN ADDITION to the comprehensive eye exam, regardless of whether or not you have a change in your contact lens prescription.
- These tests are for contact lens wearers only and include:
- Measurement of the curvature of the cornea to determine the proper parameters of a contact lens which will best fit each eye, and for previous wearers, to assure that your current contact lenses are still the proper fit. Corneal topography is included.
- Evaluation of the performance of the current and/or new contact lenses on each eye (visual acuity, coverage, centration, movement, tear exchange, cleanliness, etc…)
- Assessment of the ocular tissues involved in contact lens wear and determination if these tissues are responding favorably to contact lens wear.
- Choosing the correct lens materials and designs for your individual needs utilizing the latest technology available.
- Ongoing follow-up visits as needed up to 3 months. Any additional follow-up visits outside of the initial 3 months will be charged $50 per visit.
There is an ADDITIONAL PROFESSIONAL FEE associated with the Contact Lens Evaluation. This fee is dependent on the level of complexity of the fitting process and does not include the price of the contact lenses.
Level 1 $ 89 Soft spherical CL and Level 2 re-fit with no follow-up
Level 2 $155 Soft toric CL requiring follow-up visit(s) or Level 3 re-fit with no follow-up
Level 3 $199 Multi-focal soft CL, high astigmatism soft toric CL,
SV hybrid, SV RGP or CRT re-fit
Level 4 $299 Multi-focal hybrid or RGP, Multi-focal soft toric CL, or post-RK refit
Level 5 $899 Corneal Refractive Therapy (CRT) initial fitting, keratoconus hybrid or RGP,
or high myopia (>10 D) medically necessary, or post-RK initial fitting
Level 6 $1750 Scleral Lens Fitting
If you have vision benefits, your exam co-pay is only for the comprehensive portion of the exam. Contact lenses are considered an elective form of vision correction; therefore, the contact lens evaluation is NOT covered by the comprehensive exam coverage under your vision benefits. Unless your vision carrier provides some reimbursement toward your contact lens evaluation and/or contact lenses, you are responsible for the full amount of the contact lens evaluation fee on the date of service.
I have read and by signing, I understand that if I choose to be fit with contact lenses, I am financially responsible for all fees not covered by my vision benefits.