Cancellation Policy:

Because we value and respect your time, we do not overbook our schedule.  We kindly ask that you do the same for us.  Therefore, we require a 24-hour cancellation notice to allow adequate time for us to book another patient in your slot if possible. We reserve the right to charge $50 for any no-show appointments or cancellations without 24-hour notice.  

Financial Arrangements

Knowing Your Insurance:

I acknowledge that all insurances must be verified PRIOR to my appointment and it is my responsibility to accurately provide this information to Nipomo Optometry. Any insurance verified after the appointment is scheduled will require the patient to submit a receipt directly to their insurance and the visit will be self-pay. Payment will be due at the time of the appointment.

I hereby assign all medical benefits to which I am entitled including Medicare, private insurance and any other health plans, to Nipomo Optometry.  A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment. If my insurance company has not reimbursed Nipomo Optometry within 60 days, I may be billed for any services or products that I have received. If we later receive payment for your insurer, we will refund any overpayment to you. I certify that my responses on this form are accurate to the best of my knowledge.

Nipomo Optometry retains the right to post pone your appointment should any insurance information be missing or insufficient. We will notify you should we need more information, lack of response may result in a delayed appointment date.

Vision Plan Insurance:

I acknowledge that a Vision Plan (Routine) covers routine eye examinations, refractions, and may cover materials (contact lenses, glasses, etc) as specified by my plan benefits. I understand that Medical Examinations and Treatments are NOT covered under my Vision Plan. I understand that services related to medical conditions will be billed to my Medical Insurance or, if no applicable medical coverage exists, these services are my responsibility at the time of service.

Refraction:
Refraction (testing for best corrected Visual Acuity also known as “glasses Rx”) is not covered by medical insurance or Medicare. In the absence of qualifying vision coverage, Refraction fees are the responsibility of the patient. Best Correct Visual Acuity Refraction-$50

Dilation: 
Please note that your eyes may be dilated during your examination at the doctor’s discretion. Dilation of your pupils may blur your vision and make you sensitive to light for several hours after your examination. It is important to refrain from driving and performing precision work with tools when your vision is blurred from dilation. It is not possible to predict how long the effect of dilation will last or how much your vision will be affected, although most patients recover within 4 hours. We recommend that you wear sunglasses when your eyes are dilated and consider bringing a friend/family member to drive you home. 

Glasses and Contact Lenses:
I certify that I understand cancellations on eyeglasses are not permitted as all eyeglasses are custom crafted for each patient with their unique prescription. I certify that I understand that there are no refunds or exchanges and that all sales are final unless covered under manufacturer warranty or office warranty programs.

Contact lenses are FDA class II medical devices that have the potential for serious complications if not used and fitted properly. For that reason, the standard of care and the requirements of the California State Board of Optometry require an annual examination for renewal of a contact lens prescription. In addition to general eye health assessment, the doctor will assess issues related to contacts such as abnormal blood vessel growth, corneal damage, chronic inflammation, hygiene, discomfort, and poor surface compatibility, along with any vision changes. The Contact Lens Management Fee covers any lens related follow-ups for a 90 day period. If you cannot complete the fitting procedure in the allotted time due to missed follow up appointments, there will be an additional fitting fee applied.

By signing, I acknowledge that I understand the policies regarding the fitting of contact lenses and agree to the associated fees. I understand that these fees are an estimate and are subject to changes based on the doctor’s final assessment. I also understand that improper usage of contact lenses as prescribed can lead to vision loss and permanent eye damage. I understand that if an infection is present, I will need to be treated under my medical insurance prior to being refit with contact lenses.

Are you interested in renewing  your contact lens prescription?*

Optomap

This is the most important part of every patient’s eye exam:  the health of the retina.  Optomap is a digital image of the retina produced by scanning laser technology that can capture 82% view of your retina at one time.  Traditional examination and imaging typically only show 15% or less of your retina at one time. Life-threatening disease like cancer, stroke, and cardiovascular disease can be present in your retina before you have symptoms.  Diseases such as retinal holes & detachments, glaucoma, and macular degeneration that can lead to loss of vision are detected by this technology.   

Including the Optomap as part of your annual comprehensive exam provides:

• A scan to show a healthy eye or detect disease
• A view of the retina, giving Dr. Palmer a more comprehensive view than they can get by other means.
• The opportunity for you to view and discuss the image of your eye with Dr. Palmer during the exam.
• A permanent record for your file, providing a baseline which allows Dr. Palmer to view new images each year to check for changes. 

Dr. Palmer is requiring the Optomap screening be done every year, for all comprehensive exams. The fee is only $39.00 and not usually covered by insurance.

Notice of Privacy Practices:

This form is posted in the office and we will gladly provide you with a copy of this notice if you would like to keep one for your personal records. This notice describes how your personal health record information may be used or disclosed and how you may gain access to this information. Examples of uses of your health record information include patient recall, prescription verification or request, and for co-management with another health professional. Signing below indicates that you have been made aware of our privacy practices.