Download File - Goldsmith Eye Care

Contact Lens Policy
Contact lenses are an “Undetermined” benefit by most insurance companies. This means that depending on your insurance
company and your specific policy, the fees for the fitting, evaluation and materials May Not Be Covered, even if there is a
medical condition. If your insurance company determines this is a covered benefit and payment is received from your
insurance company, Goldsmith Eye Care PC will refund those fees to you, providing your account is in good standing. If you
have any questions at all, please feel free to call us.
GOLDSMITH EYE CARE PC REQUIRES:
*The contact lens fitting/re-evaluation charge is due on the day of service.
*Payment of 50% is due at the time of ordering and the remainder is due upon delivery of the contacts.
*For your convenience, we can mail your contacts lenses. Payment must be made in full with a fee of $7.00 added for
shipping and handling.
RETURN POLICY FOR CONTACT LENSES:
If there is a problem with your contact lenses, they must be returned within 60 days to receive credit or to exchange. OPEN
or MARKED boxes WILL NOT be returned or exchanged for any reason.
A COMPLETE EYE EXAM is required within the last year before a patient can be fitted for contact lenses or any new
contacts can be ordered. A complete eye exam includes:
*A complete medical and ocular health history
*A pressure check for glaucoma
*An evaluation of the pupils and extra ocular muscles
*A slit lamp examination of the anterior portion of the eye
*A retinal evaluation (done commonly after dilation)
A REFRACTION is also required to determine a contact lens prescription. Per billing guidelines, this is a separate charge and
may or may not be covered by insurance.
A CONTACT LENS FITTING is required for the fitting of contact lenses. A contact lens fitting includes:
*A keratometric reading of the eyes
*Diagnostic contact lenses to ensure comfort for the patient and ocular health
*Instructions on how to insert and remove the contact lenses
*Evaluation and selection of the proper lenses and care system for the patient
*Follow up visits up to 90 days to ensure proper contact lens fit.
CONTACT LENS FITTING FEES:
Spherical Soft Contact
$35.00
Toric Soft Contact
$50.00
Multifocal/RGP
$75.00
Specialty Fit
Doctors Discretion
***PER BILLING GUIDELINES, this is a separate charge and may not be covered by insurance***
All prices include 90 day follow up and 90 day warranty on breakage or re-designs. Loss is not warranted.
A CONTACT LENS RE-EVALUATION will be done at each annual exam. A contact lens re-evaluation includes: A keratometric reading of
the eyes if a change is suspected, evaluation and assessment of your contact lenses and corneal health, and diagnostic lenses if a change
in power is determined or comfort has changed- costs are same as above.
I HAVE READ THE ABOVE AND AGREE TO PAYMENT ACCORDING TO THIS POLICY:
Patient Name:______________________________________________
Patient Signature:___________________________________________
Date:_______________________________