Forms

Financial Authorization Policy

Patients, or the legal guardians of patients under the age of 18, are financially responsible for the full payment of any and all services provided. Valid credit or debit cards are required at every appointment. Copays and any outstanding balances will be collected prior to all appointments.

ReFocus will keep each patient’s Credit Card Authorization Information on file. Should there be a patient balance post-insurance adjudication, the patient’s card will be charged for the outstanding balance.

Medical vs. Vision Benefits Notification

Medical Eye Exam

Related to an eye complaint or pre-existing condition:

Previous medical diagnosis, including but not limited to: cataracts, glaucoma, diabetes, thyroid eye disease, Plaquenil toxicity, etc.
Any eye-related complaints, including but not limited to: eye discomfort, redness, tearing, etc.

Routine Eye Exam

Eye exam done every year or every other year
No pre-existing condition(s)
General eye health check
No diagnostic testing would be done with this type of visit
No eye complaints of any nature

OUR MARYLAND OFFICES DO NOT PARTICIPATE WITH ANY VISION PLANS.

Our RI, PA, NJ, and SOME of our CT clinics do accept vision plans.

In locations that do not accept your vision plan, or, if you do not have vision coverage, routine coverage must be through your medical insurance policy.

Refraction Fee Disclosure

The refraction is the part of the exam in which ReFocus Eye Health checks to see if you need a new eyeglass prescription. Medicare and some other medical insurance companies do not pay for this service. Should a refraction be needed, in discussion with your doctor, an additional fee may be charged for this service. Charges for additional screening procedures may also apply. Before the exam, we will inform you of any additional charges related to a refraction and other procedures that you elect to have performed.