Patient Registration Online Form New and established patientsDate Date Format: MM slash DD slash YYYY LocationHopewellLambertvillePlease complete the entire form and sign the last (2) pages – then submitName* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl 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RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile Phone*Work PhonePrefer CommunicationHomeMobileWorkEmailEmployerEmail* In case of an emergency: whom should be contactedSpouseSignificant OtherMotherFatherCaregiverName First Last Your Date of Birth Date Format: MM slash DD slash YYYY Social SecurityMarital Status*ChildSingleMarriedDivorcedWidowedBilling and Insurance: Payment for Services: Who(m) is responsible for the patientSelfParentSpouseSignficant OtherCaregiver - FacilityAcademic InsitutionPerson Responsible Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile PhoneMedical Provider / PharmacyPatient Name First Last Family DoctorLocal PharmacyMail Order PharmacySocial HistoryOccupationDo you require Safety eyewear for workYesNoHobbies / AvocationDo you require Safety eyewear for hobbyYesNoRace (optional)deferCaucasianAfro AmericanAsianHispanicIndian - AsianAmerican IndianOtherReferred byInsurance or Vision PlanInternet SearchFriendPhysicianNewspaperYellow pagesOtherIf Physician / Friend / Other, please specifyMedical Insurance and Vision Plan InformationPrimary Medical Insurance CompanyAetnaAARPBlue Cross Blue ShieldCignaHorizonHorizon NJ HelathMedicareOxfordQualcareUnited HealthcareOther: Please specifyOther - Please specifyName of the InsuredInsured relationshipSelfSpouseSignificant OtherChildInsured’s Date of Birth Date Format: MM slash DD slash YYYY Program Name on CardInsured’s Social Security NumberProgram ID# on CardGroup #Secondary Medical Insurance CompanyAetnaAARPBlue Cross Blue ShieldCignaHorizonHorizon NJ HelathMedicareOxfordQualcareUnited HealthcareOther: Please specifyOther - Please specifyName of the InsuredInsured relationshipSelfSpouseSignificant OtherIf SpouseWifeHusbandSignificant OtherMotherFatherCaretakerInsured’s Date of Birth Date Format: MM slash DD slash YYYY Program Name on CardInsured’s Social Security NumberProgram ID# on CardGroup #Vision PlanDavis VisionEyemedMetropolian Life (VSP)NVA (National Vision)SpecteraVBA Vision Benefit PlanVSP (Vision Service Plan)Other: please specifyOtherName of the InsuredInsured relationshipSelfSpouseSignificant OtherSpouseHusbandWifeSignificant OtherMotherFatherCaretakerInsured’s Date of Birth Date Format: MM slash DD slash YYYY Program Name on CardInsured’s Social Security NumberProgram ID# on CardGroup #Eye Care Provider Authorization to obtain previous records: SignaturePatient Name First Last Family DoctorAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Last eye Exam Date Format: MM slash DD slash YYYY Previous Eye DrAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Eye - Ocular HistoryPrimary Reason for your visit todayDo you wear eyeglasses?YesNoReason for GlassesChoose an item.Nearsighted (Myopia)Hyperopia (Frasighted)Presbyopia (Older eyes > 40 )Post OperativeDo you wear contact lenses?YesNoType of Contact lensChoose an item.Soft Daily DisposableSoft 2 week replacementSoft 1 month replacementSoft 3 month replacementSoft 6 month replacementGas PermeableHybrid (Soft / Gas perm combination)ScleralWhat SolutionChoose an item.BiotrueCompleteOptifreeRefine LiteRefine On Step PeroxideClear Care peroxideGeneric MultipurposeBoston Gas PermeableLobob Gas PermeableOptimum for Gas permeableOtherHave you had any injuries to your eyes in the past?YesNoIf yes: SpecifyHave you had any infections to your eyes in the past?YesNoIf yes: SpecifyHave you had or are you being treated for cataracts, glaucoma, corneal or retinal concerns?YesNoHave you had any eye surgeries?YesNoIf yes: SpecifyChoose an item.CataractLASIKPRKCornea: Tansplant, CXL , DSEK, DALKGlaucoma LaserGlaucoma SurgeryRetinal Repair for detahcment or tearDiabetic LaserInjections for macular degeneration or diabetic retinopathyOther or list if multiple proceduresOther / Multiple ListDo you have allergies to MedicationsYesNoIf yes: SpecifyMEDICAL HISTORYDo you have any medical concernsYesNo If yes complete below chart1 (HEENT) Ear / Nose / Throat / Headaches: ConditionYesNoConditionMedications/ TxDoes any family member have a similar condition: Please list2 Cardiovasular (Heart / High Blood Pressure / Angina / Arrythmia …YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list3 Respiratory (Smoker, Emphysema, Asthma,…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list4 Gastrointestinal (Reflux -GERD, Colitis, Crohn, Cancer, Irritable Bowel.)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list5 Gynecological or Genitourinary (Bladder…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list6 Musculosketetal / Rheumatology (back, arthritis…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list7 Integumentary (skin- acne, eczema, psorasis..)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list8 Nervous (Multiple Sclerosis, Parkinson…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list9 Psychiatric Concerns (depression, anxiety…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list10 Endocrine ( Diabetes, Thyroid, Adrenal…)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list11 Do you have a history of cancer?*YesNoType of cancerDoes any family member have a history of cancer?YesNoPlease list12 Hematological (Blood / Leukemia / Anemia / Sickle Cell, Tays Sachs…..)YesNoConditionMedications/ TxDoes any family member have a similar condition: Please list13 Allergic / ImmunologicalYesNoConditionMedications/ TxDoes any family member have a similar condition: Please list14 Constitutional Concerns: weight loss / fever / fatigue/ weakness……YesNoConditionMedications/ Tx15 Hx of COVID or exposure to COVIDYesNoIf yes: When16 Other ConcernsYesNoConditionMedications/ Tx16 Social HistoryUse of alcoholNo use of alcoholOccasional 1x - 2 x per weekOccasional 3x-5 x per weekGreater than 5 x weekHx of Alcohol AbuseD/c use of Alcohol due to abuseRecreational drugs,…No use of recreational drugsUse of Marjiuana occasional useUse of Marjiuana 1-2 x weekUse of Marjiuana 3-5 x weekUse of Marjiuana greater than 5 x weekHx of substance abuseRecovery from Substance abusePresent Use of Drugs/ Substances: Please specifySpecifySmokingYesNoIf yes TypeIf yes frequencyAny additional comments or other concerns to be discussed with the doctorI have read the following: Authorization for Insurance Submission / Responsibility for Payment of Services Rendered / Accept Responsibilities for Payment of Diagnostics Procedures Not Covered by Insurance / Health Insurance Portability and Accountability Act" I acknowledge that I have read and accept: X Signature Print Name "I have read the following: Medicare Beneficiary Agreement / Managed Care - Vision Plan BenefitsI acknowledge that I have read and accept - Print name and signAuthorization for Insurance SubmissionI agree to pay for the services rendered and the materials fabricated at my request. I request that payment of authorized Medicare / Medicaid / Medigap or other Health / Vision Care insurance benefits be made either to me or on my behalf to Hopewell - Lambertville Eye Associates and/or suppliers for any services furnished to me by that provider of service or supplier. I authorize any holder of medical information or Medicare information about me to be released to the Health Care Financing Administration and its agents or other insurance(s), or Medigap Insurer ( ) , to include any information needed to determine these benefits or the benefits payable for related services. There are several procedures that may or may not be covered by the medical nor the vision plan: A procedure is only covered based on Insurance CPT – ICD guidelines. Some of the procedures are as follows: Refraction (not covered by medicare); corneal topography - aberoometry, Diabetic Clearpath, Wellness Imaging, Dry Eye Procedures (MIBO), and imaging if combined with dilation. Responsibility for Payment of Services Rendered I agree to pay for the services rendered and the materials fabricated at my request and acknowledge that my insurance company can deny payment for services. I agree that if my insurance carrier does not pay Hopewell - Lambertville Eye Associates within 90 calendar days after submission, for services rendered to me, I shall take full responsibility for these charges. If an insurance payment is received after I have reconciled with Hopewell - Lambertville Eye Associates, I will be refunded the amount of payment stated on the “explanation of benefits” provided by my carrier. Accept Responsibilities for Payment of Diagnostic Procedures Not Covered By Insurance It is possible that some of the procedures performed during the eye examination may not be covered by my vision or medical insurance. It has been explained to me the importance and reason for these specific eye care procedures which may or may not be covered by my insurance. If these procedures are not a covered benefit, I will accept the responsibility for the payment of non- - covered charges. If I should choose not to have a procedure completed, I will not hold Hopewell - Lambertville Eye Associates responsible for any financial nor medical ramifications due to my actions. Health Insurance Portability and Accountability Act of 1996 (Privacy of Patient Records) We respect our legal obligation and your rights to privacy by maintaining your medical records in complete confidentiality and obligated by law (HIPAA) to give you such notice. Based on the HIPAA regulations, we cannot share or disclose information from your medical records without your written consent. This implies any and all non - medical or non-licensed healthcare offices or third party vendors. We ask you to sign this form to allow us to disclose only the information required to: Have other licensed medical providers who(m) might / will assist in your medical and / or eyecare Your insurance carrier in order to process claims and / or a federal or state agency mandates for public health concerns. Be able to send you reminders of care utilizing healthcare codes in order to assist in your acquisition of referrals when required. If a copy of records are requested by yourself or designated legal guardian, a separate "Record Release" form must be signed by the individual and / or guardian. Records can then be released to the authorized party. Your records are held safe within the confines of our office with limited access to doctors and staff. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s Privacy Contact at [84 East Broad Street, Hopewell, NJ 08525 or 16 South Franklin Street, Lambertville, NJ 08530]. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. My physician will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure except: (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. The use or disclosure requested under this authorization will result in direct or indirect remuneration to my physician from a third party. MEDICARE BENEFICIARY AGREEMENTMedicare Beneficiary Agreement (Medicare only – used if Medicare will deny payment of services) Medicare will only pay for services that it determines to be reasonable and necessary under section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. Medicare is likely to deny payment for the following procedures as non - covered procedures: {Refraction (92015), Anterior Segment Photos (92285), Spectacles or Contact Lenses are non-covered items by Medicare other than post-operative cataract extraction, I have been notified by my physician, at Hopewell - Lambertville Eye Associates, that he or she believes that, in my case, Medicare is likely to deny payment for the service(s) identified above, for the reason(s) stated. If Medicare denies payment, I agree to be personally and fully responsible for payment. TO ALL MANAGED CARE – VISION PLAN and Medicare PATIENTS Please be aware that your benefits are limited and that you will be responsible for specified payments of your examination, spectacles, and / or contact lenses. (i.e. co - pays and non-covered procedures) that are not covered by your carrier. These plans are vision only (annual – wellness - preventative health care related). These are not medical plans. Medical concerns, in general, will require a return visit with a referral. Certain procedures may not be covered by your plan such as corneal topography, automated screening visual fields, and dilated retinal examination. A dilated retinal examination (the use of drops to fully examine the internal eye health) is considered the most important part of the examination. **Additionally, contact lens fitting and progress evaluations are not considered as part of the annual examine as defined by vision policies. Therefore, there will be an additional charge for lens evaluations as well as any lens refit (if required). Eyeglass Benefits Please be aware that managed care vision plans such as EyeMed, Spectera, VSP, Davis and others, have a specified and limited eyeglass frame selection and options. If you are unclear with your benefits, our staff will assist in determining your benefits or you are encouraged to call your provider. Hopewell – Lambertville Eye Associates, by contract with the various vision plans, have a selection of frames or contact lenses specified by your carrier. However, we feel that as a courtesy to our patients, we have extended this benefit above and beyond what we are contracted to offer. All plans have a “retail” allowance in lieu of their specified frame selection. Please check with our staff if this is an option. Contact Lens Benefits Managed care vision plans such as EyeMed, Spectera, VSP, VBA, NVA and others, have very limited benefits for contact lens materials. Professional fees are separate and not covered by the vision plan – therefore these fees are the responsibility of the patient or their guarantor. Material benefits by a vision plan is for contact lenses or eyeglasses not both. If contact lenses are purchased through a vision plan, our office offers courtesy discount on the purchase of eyeglasses. This discount is not part of the vision plan, but a courtesy extended to our patients by our office. Professional and Products Fees All additional professional and product fees due, inclusive of co-payments, charges on eyeglasses or contact lenses are required to be paid in full prior any order processing. The patient understands the all above statements and will assume the listed payment responsibilities. Signature*