Refraction Understanding and Agreement Form

Routine vision exams are often not covered by many medical insurance company contracts.  Many insurance companies have determined that nearsightedness, farsightedness, astigmatism, blurry vision and some other diagnostic categories or complaints, which can be corrected simply with glasses and/or contact lenses, are NOT considered "medical" conditions.  The procedure for screening for these problems and the determination of one's eyeglass or contact lens prescription is called a refraction.  If your company does not provide for "routine" vision coverage, the "refraction" portion of the eye examination may not be eligible for reimbursement.  If you are uncertain about your insurance coverage, please contact the insurance company for clarification.

If we submit charges to your insurance company and the company determines (even at a later date) that the charge is not covered by your contract, you will be responsible for payment yourself.

Please sign below to indicate that you understand and agree to these terms.  Our staff, of course, is available to answer any questions you might have.

PATIENT NAME (please print) __________________________________________________________________

Signature ____________________________________________________________________________________
                                                 (patient or parent/guardian if patient is a minor)