Signing this section is required of all patients before services are
NOTICE OF PRIVACY PRACTICES
The full Notices of Privacy Practices of Budaful Eyes, P.A. is available by request
from our check-in desk.
I understand that, under the Health Insurance Portability & Accountability Act of 1996
(HIPAA), I have certain rights to privacy regarding my protected health information. I
understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers
who may be involved in that treatment directly or indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician
I have read and understood the Notice of Privacy Practices of Budaful Eyes, P.A. I understand that I
may request in writing how my private information is used or disclosed to carry
out treatment, payment, or healthcare operations. I also understand that you are not required to
agree to my requested restrictions, but if you do agree then you are bound to abide by such
For patients using insurance:
- I understand that payment for services is due in full at the time services are rendered.
- I understand that vision plans only provide coverage for routine eye examinations and
discounts on glasses and contacts. I also understand that vision plans do not cover for any
medical eye problems that I am having.
- I understand that my medical insurance will be billed today if I am having any medical eye
problem as determined by the doctor, and that I am responsible for any and all deductibles,
copayments, and coinsurance amounts under the terms of my medical plan.
FOR PATIENTS INTERESTED IN CONTACT LENSES
Contact lenses are FDA regulated medical devices. Contact lens professional fees cover the
additional testing taken to properly evaluate and fit your contact lenses for optimal health and
The contact lens fitting fees are as follows:
|•Single vision, non-astigmatism:
|•Single vision, astigmatism:
|•Multifocal or monovision:
|•Specialty Contact Lens Fittings:
||$150.00 & up
|•Training for 1st time wearers:
Fitting fees cover prescription trial lenses and 60 days of follow-up care. If you return beyond the
initial 60 day period, an additional visit may be charged ($50). Fitting fees do not cover the cost
of contact lens supplies and cannot be refunded.
I have read and understood the above information and acknowledge that any fees not covered by my
insurance will be my responsibility and must be paid at the time of service.
ABOUT YOUR APPOINTMENT
In order to provide comprehensive quality eye care, all routine exams will require mandatory
Optomap retinal imaging. These images assist in the detection of retinal diseases and other
eye conditions. These scans are an additional $39 in the event that they are not
(Note: This service is covered if you are paying out-of-pocket.)
- A patient is considered late when they arrive after their scheduled appointment time. We
will try to work you into the next available time, but other patients who have arrived on
time for their appointments may see the provider first.
- If you cannot keep your appointment, please call us at least 24 hours. Patients that
miss two consecutive appointments will be charged a $50 no-show fee and the fee must
be paid before another appointment can be made. Please keep in mind that three missed
appointments may be cause for discharging a patient from the practice.
- Unpredictable situations may occur with patients who require extra attention during the
course of the day. We appreciate your understanding when there are delays and the same
courtesy will be extended to you if you have additional needs.