Thank you for trusting TACOMA EYE with your eyecare needs! Attention patient/patient guardian: Please read & sign this important document before your appointment.
Medical plans are billed when a medical condition (floaters, cataracts, dry eye, etc.) is detected. “carriers” in this agreement.
You are allowing Tacoma Eye to perform an eye exam and bill your carrier on your behalf. It is your responsibility to provide correct carrier information and prior authorizations before your appointment. Our office endeavors to verify coverage with carriers but carriers do not guarantee the information they provide us will be 100% accurate (even after carriers confirm eligibility, they still won't guarantee coverage). If you have questions about your in-network benefits, out-of-network benefits, prior authorization requirements, etc, contact your carrier for clarification before your appointment. The ultimate responsibility of any monetary balance owed to Tacoma Eye is yours and not your carrier. Our office uses a collections agency to collect unpaid balances.
Digital Retinal Imaging (DRI ) screening allows your optometrist to best screen, examine, and document a number of eye conditions. Your optometrist will review your DRI findings during your eye exam and let you know if dilation or any additional testing is needed. DRI will cost you $39. (If you have questions, please ask the receptionist when checking -in for your exam).
Before signing this document, take a moment to review the FAQs & policies on warranty, NSA, no-shows, etc. (Click here to access FAQs & policies on warranty, no-show, NSA, etc. )?
By signing below, patient/parent guardian acknowledge and agree to above. If you have questions simply ask the receptionist when checking in for your exam.
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