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Notice of Patient Privacy Rights, Protections and Financial Responsibilities

Services Provided Without Referral Authorization

I understand it is my responsibility to know and understand my insurance benefits. I acknowledge that I will assume full financial responsibility for services rendered to me if my vision insurance carrier denies or does not cover my claim for services.

Medical Necessity

If my insurance determines that a medical service and/or material is not covered, I acknowledge that I have been notified and will assume full responsibility for the service(s) and/or materials as stated below.


I understand that I am responsible to pay all co-payments at the time of service. Co-Payments are set by your insurance company and can not be waived at any time by providers or staff of Central Eyes Optometry.


If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for the payment in a timely manner, no more than 7 days after I have been notified by insurance and/or provider. Yearly deductibles can not be waived at any time by Central Eyes Optometry.

Professional Services and Materials

I understand that I am responsible for 100% of all fees for professional services rendered on the date of service. I understand that I am also required to make payment for at least 50% of materials at the time materials are ordered. If I am supplying my own frame, I understand that all plastic and metallic products degrade over time and I will not hold Central Eyes Optometry or my insurance carrier responsible for accidental lab breakage. If I do not pick up my materials within 60 days from my initial order, my materials will be returned to the laboratory and my initial deposit will not be refunded. If I am to receive contact lenses in the mail, I understand I must pay in full prior to order submission.

Our patient satisfaction guarantee applies to single vision and progressive lenses. We use only premium single vision optics and premium progressive lenses (known as ‘no-line bifocals’). Fewer than 1% of our patients express difficulty adapting to progressive lenses. We will remake a non-adapt progressive lens one time and in the same frame. If still unsatisfactory, we will replace the progressive design with a lined bifocal or single vision lens in the same frame. While we make every attempt to solve these very rare issues, no refund will be given in the instance that a patient is unable to adapt to multiple lens designs.


I understand that under the Health Insurance Portability and Accountability act of 1996 (HIPAA), of which I have been offered a copy, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up care among various healthcare providers who may be involved directly or indirectly, may be used to obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician certifications.

Optomap Retinal Screening Photo Acknowledgement

Central Eyes Optometry is committed to providing the highest quality care for our patients, because of this we perform Optomap ultra-widefield Retinal Screenings on all of our patients, annually.

This procedure allows for fast, non-invasive image acquisition of up to 200˚ of the retina in both color and auto-fluorescent photos that will be reviewed with you and your doctor. The photos remain a part of your permanent record, they allow for a more thorough exam, and enable your doctors to make important comparisons should potential vision-threatening conditions manifest over time. This is similar to a primary care provider obtaining annual labs or your dentist obtaining X-Rays.

Macular degeneration, ocular melanomas, retinal holes/tears/detachments, diabetic retinopathy, and many other diseases are detectable through Optomap imaging, often before symptoms become noticeable by a patient. Early detection of eye disease is crucial to maintaining our best vision throughout your life. The providers of Central Eyes Optometry strongly believe this imaging is an important part of your exam and therefore prescribe it annually.

While the Optomap does not replace the need for dilation in all cases, your doctor may still recommend a dilated exam if visual symptoms or findings indicate a need to do so.

The Optomap procedure has a co-pay of $39.00 that is not always covered by insurance. *

The Optomap procedure might be covered, if being used to actively follow eye disease.

*Medicare and OHP DO NOT cover the cost of a screening photo, and you will be responsible for your co-pay. However, Medicare and OHP WILL cover photos to actively follow disease.

Cancellation and No-Show Policy

We require at least 24 hours’ notice if you must cancel your appointment. We understand that life and/or emergencies may prevent you from making your scheduled appointment, but this time is reserved especially for you. We will forgive one missed appointment, but if two appointments are missed or cancelled without 24 hours’ notice, you will be required to pay a $50 deposit before we can put you or a member of the household on our schedule. This deposit will be put towards your visit and any remainder refunded if attended. However, the deposit is forfeited if the appointment is again cancelled with less than 24 hours’ notice or not attended.

By signing at the end of the intake process, you are agreeing to the terms of these policies. We will collect any applicable co-pay at the time of your exam.