Patient information

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Billing information

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Primary Vision Insurance

Primary Medical Insurance

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Eye History

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Contact Lens Wearers Only

Family Eye History

Does anyone in your family have any of these eye conditions?

Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems

Social History

Policy's and consent

Financial Policy & HIPAA Privacy

Insurance submission policies

We will bill insurance claims to primary and secondary carriers as a courtesy to our patients. It is your responsibility to provide us with the most current insurance information. You must also have a referral, when required, before being seen by our office. Payment In full will be required if the necessary referral was not obtained. We accept reimbursement from all participating insurance plans. Payment of co pays, deductibles and non-covered options are due at the time of service. Parents/ Guardian requesting treatment for a minor will be responsible for the payment on that account. Your insurance policy is a contract between you and the company you have chosen, therefore, it is your responsibility to know what your benefits are. We will attempt to verify benefits before of at time of service; however all insurance companies have a disclaimer that the information / authorization obtained may not be accurate and is subject to review at the time the claim is processed. You may be billed in the event that your insurance plan denies a claim or does not pay in a timely manner. All fees are ultimately your responsibility.

Collections and Returned Check Fees

All delinquent accounts, will be sent past due and final notices. If there is no response to our notices within 10 days, you will be referred to an outside collection agency. If your account is referred to collections, you will be assessed a 30% administrative fee in addition to you outstanding balance. There is a $30.00 service charge on all returned checks. Accounts that do not resolve a returned check issue within 14 days of notification will be sent to collections and assessed a 30% administrative fee in addition to the $30.00 fee.

Financial Hardships

Our practice believes financial hardships should not prevent medical care. Please discuss such matters with our staff immediately

HIPPA Privacy Acknowledgement

By Signing this Receipt of notice of Privacy Practice (the "Notice"); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that the location may use and disclose necessary personal health information ( for example: my name, address, subscriber identification number, eye exam information and or type of products provided ) to another party to permit its administrative duties, provide me with the eye care services and products, process my vision benefits claims and communicate with me regarding vision care services provide by the location. I authorize this location to submit my vision benefits claims to my plan sponsor or health insurance to receive reimbursement directly for services I have received.

I acknowledge that I am aware that my information may be shared with Pearle Vision and other parties as part of an examination reminder service. I also realize that my information will be shared with Pearle Vision to compare mailing lists to help avoid duplicate mailings of coupons as well as service and product information I can be assured that this location does not sell my personal health information of any kind to a third party for such parties own use other than what has been indicated above.


Refraction is the process by which your doctor determines the lens combination that enables you to see the best. This service is performed to determine your prescription for near and far vision. The refraction will also provide information about your eye-muscle balance, focusing strength and ability.

Refraction Change For Medicare and Commercial Insurance Patients

The refraction is not covered under the Medicare program, but it is one of the most frequent and important test performed by the doctor. Under Medicare and Commercial programs, the beneficiary is responsible for paying this fee. Our fee for the refraction is $40.00, which we collect at the time of service for all patients. If we receive payment on the refraction from your insurance company our corporate office will reimburse you in a timely manner.

Please sign below that you have read and understand the above statements.


A retinal thickness map and ganglion cell complex assessment giving the doctor detailed information simply not available with other methods. Captures high definition cross sectional images of your retina.

Due to Covid-19 we will be performing an optomap exam on all patients.

This gives us a panoramic image of the surface of your retina with less exposure and lower risk to you and the staff. These images help the doctor assess the health of your eyes and check for conditions including macular degeneration, glaucoma, and retinal detachments. These problems can threaten vision without warning or symptoms.

The optomap test will be billed as part of your comprehensive examination. An additional fee of $39 will be added to your exam co-pay. It is possible your medical insurance may cover the cost of the optomap. Please provide your medical insurance information to the staff.

If you wish to decline this test, please ask an exam staff member for a waiver form stating that you understand the risks of not getting this test and although your doctor believes that the optomap is a critical part of your eye exam, you are still choosing to waive this test
Contact Lens Consent

This involves developing a prescription of optical and physical characteristics of a contact lens, combined with medical supervision of adaptation of corneal lens, in one or both eyes. The patient understands that the wearing of contact lenses is neither completely safe nor benign and requires periodic evaluation. The patient has been advised of the dangers and possible loss of vision due to complication of contact lens wear.

The patient is aware that their contact lens prescription will be valid for up to one year barring any medical complications preventing contact lens refills. After this period, a comprehensive exam and contact evaluation must be completed before the contact prescription can be renewed. Contact lens fittings/evaluations have a separate fee depending on the patient's contact lens prescription, this is due to the doctor having to evaluate the best contact lens to fit your eyes and prescription requirements. The Fitting/Evaluation Fee is non-refundable and must be paid at time of the visit. Should the patient decline contact lens fitting/evaluation they are aware that they only have within thirty days to come back and be evaluated. And at that time contact lens evaluation fee must be paid.

First time wearers, ONLY, must go through a training process, in which they must successfully insert and remove the lenses twice before they are allowed to leave with trial lenses. Contact lens trainings will be performed with patient and trainer only, this is to avoid any outside interruptions, trainers must have the trainees full attention in order for a successful outcome. Each class is a 15 minute session to avoid irritation to the patient's eyes. Contact fitting fee must be paid regardless of training outcome. If trainee is unable to successfully insert and remove lenses they can schedule another training during a designated training time within thirty days initial of initial eye exam.

Current Wearers:
  • Sphere: $55
  • Toric: $90
  • Multifocal : $100
  • Toric Multifocal : $125
New Wearers:
  • Sphere $155
  • Toric : $190
  • Multifocal $200
  • Toric Multifocal $ 225
Given this information and fully understanding the risks involved and I am aware that all subsequent contact lens follow ups/trainings must be completed within 90 days of initial exam:

*WARNING: You should be aware that your eyes may change with time and contact lenses that were initially fitting properly may no longer be appropriate and may endanger your eye health. You should see your eye doctor periodically to ensure your lenses are fitting properly.


You agree, in order for us to service your account or to collect monies you may owe, EHG Services of NJ LLC, The Optical Group of NJ LLC d/b/a Pearle Vision and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you be sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and agree that EHG Services of NJ LLC, The Optical Group of NJ LLC d/b/a Pearle Vision, its employees and/or agents may contact me/us as described above.