PLEASE BRING INSURANCE CARDS TO APPOINTMENT.
We have incorporated a highly sophisticated retinal imaging camera into our practice. The retinal camera can detect early retinal pathology that is often associated with many common ocular diseases. This technology can help identify diseases such as early glaucoma, diabetic retinopathy, macular degeneration, tumors, and vascular problems. The test would provide the optometrist with important baseline diagnostic information, and give a permanent photographic record of your retina for future comparison.We recommend that all of our patients over the age of 10 receive this test. It is especially important for those patients who have a history of diabetes, high blood pressure, high cholesterol, or headaches. It is highly recommended if you have a strong prescription or if you have any family history of glaucoma or macular degeneration.This state of the art procedure requires an additional 5 minutes of your time. The fee for this test is $35.00. Insurance or vision benefits do not generally cover this testing. However, if we pick up an abnormality and recommend further testing, insurance may cover the additional fees.Please check the appropriate box below:
I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits either to myself or to the party who accepts assignment. I understand that I am responsible for any balance due for services and/or products that are deemed "not covered" or denied or delayed (over 60 days) by my benefit plan.
By signing/typing your name on the field below, you have read, understand, and acknowledge that you have received a copy of the Inclima Eye Care Notice of Privacy Practices.
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