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
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.
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
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.
SD-OCT & OPTOMAP CONSENT FORM
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
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
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
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
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
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.
- Sphere: $55
- Toric: $90
- Multifocal : $100
- Toric Multifocal : $125
- Sphere $155
- Toric : $190
- Multifocal $200
- Toric Multifocal $ 225
Given this information and fully understanding the risks involved and I
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.
CONSENT TO CONTACT
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.