Vision Source – Albany Eye Care
Secure Form
Please provide your insurance cards to the receptionist.
As a service, we will process your insurance claim. However, it is your responsibility to determine if this practice or your optometrist is participating with your insurance plan. We will not be responsible for penalties imposed on you by your plan, if we are not participants. Please note, that MOST medical insurance plans DO NOT cover routine eye health exams, eye glasses or contact lenses.
** I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of benefits to be paid directly to Vision Source - Albany. I understand that I am financially responsible for charges not paid by insurance. I understand that any fees incurred for collection of an unpaid balance will be my responsibility. I acknowledge that all of the above information is correct.
Contact lens examinations include additional tests and procedures that are not performed in your routine eye exam. These additional tests and time spent with your doctor are necessary for a proper contact lens fitting and training. There is an additional fee for these services. If we find it is not covered by your insurance plan, you will be responsible for this charge.
Refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of eye examination and necessary to write a prescription for glasses or contact lenses. It is NOT a covered service by Medicare or most medical insurance plans. These plans consider refraction a "vision" service, not a "medical" service. Our office fee for refraction is $28.00 and is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly.
I have read the above information and understand that the refraction may be a non-covered service. I accept full financial responsibility for the cost of this service and understand it is due at the time of service. I understand that any co-payment, co-insurance or deductible I may have are separate from and not included in the refraction fee. I understand that my glasses or contact lens prescription will not be released until refraction fee is paid in full.
At Vision Source, we analyze not only your vision, but also take time to analyze the health of your eyes with detailed checks for diseases and disorders. Dilation leaves you with blurred vision and sensitivity to light for several hours. As the exclusive carrier of this technology in Albany, our patients can now receive a thorough examination through the new Optomap" Retinal Exam, without the unpleasant side effects of dilation.
The Optomap" Retinal Exam is a fast, easy and comfortable procedure that gives the doctors a complete view of the back of the eye (the retina) that was only previously possible with dilation. We can also create a digital record of your retinal health that becomes a part of your permanent file, By comparing these images each visit, we can monitor and prepare for any changes in your eye health. This fee is not included in today's exam fee. Insurance does not usually cover this procedure.
