Policies, Consent, Submit Data
Contact Lens Evaluation Agreement
Contact lenses are FDA medical device according to Chapter 147.108 of the Iowa Code that require additional testing to ensure safety and an accurate prescription. An annual contact lens evaluation is required every year for all contact lens wearers in order to prescribe contacts. The fee for this evaluation is separate from the fee for the routine eye exam and is not refundable.
Some vision plans do cover all or part of this fee, while others do not. Any amount not covered by your vision plan is due in full at the time of service.
Contact Lens Evaluation Fee:
Established Patient Contact Lens Evaluation - $69 (no change of any kind is needed)
Existing wearer for spherical or toric lenses with change - $105
Existing wearer for multifocal/monovision or RGP lenses with change - $150
New wearer for spherical or toric lenses - $150
New wearer for multifocal/monovision or RGP lenses- $195
***If you are a NEW CONTACT LENS wearer, education on insertion and removal, disinfection, cleaning, storage, and handling techniques of your contact lenses, as well as, initial solution and storage materials for regular replacement lenses is required.
All contact lens evaluation fees above includes:
- All the necessary measurements required to determine the right fit and prescription for you.
- Any follow ups needed to finalize the prescription of your contact lenses, or to address issues you may be having with your lenses.
- Additional insertion and removal training
- Trial contacts (if needed/indicated)
By signing this form, you are acknowledging that:
- Contact lens evaluation fees are non-refundable and payment is due at time of service.
- Your contact lens prescription is valid for one year.
- Proper care of your lenses is expected. Failure to properly care for your lenses may result in numerous eye problems, such as corneal ulcers.
HIPAA Privacy Act
I acknowledge that I have read and/or received a copy of the Notice of Privacy Policy of Valley Eye Clinic. I understand that the doctor may use and disclose personal health information to provide me with vision care services and treatment, process my vision and medical insurance claims, and to communicate with me as provided in the Notice of Privacy Practices.
I understand and agree that health/vision/accident insurance policies are an arrangement between an insurance carrier and myself. I understand fees for professional services rendered to me will be immediately due and payable on the date of service. Protected health information (PHI) may be disclosed or used for treatment, payment, or health care operations. I understand my medical insurance may be used in cases if there is a medical diagnosis. I hereby authorize my optometrist/medical records to be released and transferred when medically necessary.