Advance Beneficiary Notice of Non-coverage (ABN) Form in Houston, TX

Medical and Vision insurance do not cover all services. These services may include the following:

Pupil Dilation - included in exam fee

WILL BE PERFORMED AS NECESSARY. Eye drops are used to allow Dr. Ton to exam the retina for holes/tears/abnormalities. The side effects are light sensitivity and decreased ability to focus up close for 4-6 hours.

Please Initial

Yes, I consent

No, I decline

Refraction - $60 (covered by vision plans)

Needed to determine your prescription for glasses.
(MEDICAL INSURANCE DOES NOT COVER REFRACTION)

Pre-Test Bundle - $80 (savings of $30)

iWellness Exam, Topography and Retinal Photos -
Dr. Ton recommends these tests to be performed yearly.
Description of tests are below. You can choose to select individual testings and decline the Pre-Test bundle.
(NOT COVERED BY INSURANCE)

Please Initial

Yes, I consent

No, I decline

iWellness Exam - $40

Recommended for all patients age 12 and older: a quick, non-invasive light scan that allows us to see beneath the surface of your retina. This unique technology can help detect vision threatening diseases in their very early stages when they are most treatable.

Please Initial

Yes, I consent

No, I decline

Topography - $30

Recommended for all patients age 12 and older: a non-invasive technique for mapping the surface curvature of the cornea. The cornea is responsibble for 70% of the eye's refractive power so the topography is important in determining the quality of vision and corneal health.

Please Initial

Yes, I consent

No, I decline

Retinal Photos - $40

Recommended for patients age 5 and older: photos of the retina, macula, blood vessels and optic nerve (dilation not necessary for most patients).

Please Initial

Yes, I consent

No, I decline

Contact Lens Fitting/Evaluation - $75-$800

Applies to all new/returning contact lens wearers.

Dr. Ton recognizes that all eyes are different and require different care. Depending on your contact lens requirements, the following services will be provided: contact lens training, lens care kit, trials (if available), and follow up visits to finalize prescription. For patients who require additional correction or specialty lenses such as astigmatism, multifocal, irregular corneas, post surgical corneas or keratoconus, the office will provide a quote that matches each individual's needs. Once Dr. Ton has finalized your prescription, you are eligible to come back within 3 months to make changes without a follow up fee.

Contact evaluation/fitting fee is a separate charge from an eye exam and is non- refundable.

Please Initial

Yes, I consent

No, I decline

General

WHAT IS THE REASON FOR YOUR VISIT TODAY?

yearly exam

new glasses

blurry vision

headaches

flashes of light

dry eyes

contact lenses

other

If other, please explain*

ARE YOU INTERESTED IN:

computer glasses

colored contact lenses

prescription sunglasses

Latisse® (longer lashes)

VuityTM (near focus)

Upneeq® (eye lid lift)

COMMUNICATION PREFERENCE:

Text

Telephone

Phone

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PAYMENT POLICY

(CO) PAYMENTS FOR SERVICES AND MATERIALS ARE DUE AND PAYABLE AT TIME OF SERVICE. The filing of a claim for any services rendered DOES NOT GUARANTEE PAYMENT from your insurance company. You will be financially responsible for unpaid services and materials. We must emphasize that, as a medical care provider, our relationship is with you, not your insurance company. Unaccompanied minors must make payment arrangements prior to the appointment.

Please Initial

AUTHORIZATION TO RELEASE INFORMATION

A copy may be used as an original. I hereby authorize the release of any medical information to my insurance carrier or to a licensed physician concerning my illness and treatment. I also request payment of my insurance benefits to Enhance Eye Care/Dr. Jocelyn Ton.

Please Initial

HIPPA ACKNOWLEDGEMENT

Our Privacy Practice is to not to release any of your information without your written consent.

Signing below means that you have received this notice and understand the charges. If you have any questions, please ask the staff to clarify any charges prior to services being rendered. Thank you!

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Date*

Patient Name*

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Comments

This field is for validation purposes and should be left unchanged.

Advance Beneficiary Notice of Non-coverage (ABN) Form

Pupil Dilation - included in exam fee

Refraction - $60 (covered by vision plans)

Pre-Test Bundle - $80 (savings of $30)

iWellness Exam - $40

Topography - $30

Retinal Photos - $40

Contact Lens Fitting/Evaluation - $75-$800

General

PAYMENT POLICY

AUTHORIZATION TO RELEASE INFORMATION

HIPPA ACKNOWLEDGEMENT

Signing below means that you have received this notice and understand the charges. If you have any questions, please ask the staff to clarify any charges prior to services being rendered. Thank you!

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