ABN – Advance Beneficiary Notice of Noncoverage

Patient Name

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn't pay for D. REFRACTION below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. REFRACTION below.

D. REFRACTION
E. Reason Medicare May Not Pay: NOT MEDICALLY NECESSARY
F. Estimated Cost $50.00

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.

• Ask us any questions that you may have after you finish reading.

• Choose an option below about whether to receive the D. REFRACTION listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

Contact Lens Fitting Agreement

Contact Lens Fitting

The fitting fee includes:

• The Contact Lens Fitting

• Contacts lens handling and cleaning instructions

• Follow up visits up to 60 days

• Contact Lens Solution Starter Kit

• Lens changes if necessary, though the patient is responsible for any difference in cost of the contact lenses
  
  

The fitting fee does not include:

• Contact Lenses- except for disposable lenses used for fitting purposes (cost varies depending on type of lens prescribed)

• The Routine Eye Exam or Comprehensive Eye Exam

• Medical visits or treatment that may be necessary whether it is related to the contacts or not

• Contact lens follow-ups after 60 days. There will be a $30 charge for all subsequent visits after the 60 day global period.
  
  

Contact Lens Training Session

First time contact lens wearers will be provided with a personalized instruction and/or video concerning the safe care and usage of contact lenses. You must be able to insert, remove, clean and care for the contact lenses before leaving our office with the contact lenses. This session may take up to an hour to complete. If you have difficulty with successful insertion and removal, an additional training session will be required at no additional charge.

Summary of Policies

• Charges for fitting fees are due in full at the time of the fitting, and are non refundable

• All contact lenses must be paid for in full prior to being ordered.

• Follow ups and other contact-lens related services performed after the above mentioned 60 day global period are subject to a $30 fee.

• Many insurance plans do not cover the full cost of contact lens fees. You will be responsible for any uncovered costs incurred by the eye exam, contact lens fitting or contact lenses.

• Professional fees for the complete eye exam and fitting are non refundable.

• You are responsible for scheduling and attending follow up visits in order to finalize your prescription. Your prescription will not be released and contact lenses will not be ordered for you until your prescription has been finalized by the doctor.

• Contact lens prescriptions expire after one year in the state of VA. All patients are required to come in for yearly exams to ensure that your eyes are healthy and the contact lenses are still fitting well.

• Contact lens prescriptions cannot be renewed without an annual exam. Contact lens exams have a separate charge and are NOT included in your annual routine eye exam.

• We can provide your contact lens prescription if:

• You have had a contact lens exam within the last 12 months at Morgan Vision Care

• You have returned for all requested follow up exams, allowing Morgan Vision Care to finalize your prescription.

• An ocular medical condition does not exist, requiring follow up care.

• All financial obligations have been met.

Exchange Policy

Morgan Vision Care will be happy to exchange unopened unmarked boxes of contacts. However, we will not exchange color contacts for another color. The color desired needs to be established before ordering with trial colored lenses before purchasing. Therefore, when you receive your contact lens order, call the office to establish "Right" and "Left" lenses and mark them with a sticker instead of writing on the boxes. Keep in mind, rebate contact lens boxes might not be eligible for exchange if there are end labels missing that were submitted for rebate purposes

I understand that my cooperation is vital to my success with contact lenses. I have been instructed in the proper methods of lens care, risk, and handling. I agree to follow Morgan Vision Care's advice for wear as indicated in my record. I will notify Morgan Vision Care immediately if any eye or vision problems occur. If I am unable to reach Morgan Vision Care, I will call the nearest eye doctor or hospital immediately. I agree to follow the advice and instructions given to me by Morgan Vision Care. I have been told the possible risks and consequences of contact lenses. I know there are feasible alternatives, including spectacles. I understand my chances of success with contacts and I will be able to ask any questions I have about Morgan Vision Care's policies prior to ordering of lenses.

Understanding your Contact Lens Care & Professional Fees

What are contact lens professional fees for?

As a contact lens wearer additional tests are done for you that are necessary to make sure your eyes are healthy, that your lenses fit properly and to ensure that you are seeing well. Contact lens professional fees are for the extra testing including, all follow-up care (up to 60 days), diagnostic trials, contact lens solutions and time taken by the doctor each year to properly evaluate your contact lenses.

What types of additional tests are needed?

Corneal topography is one example of test done for contact lens wearers. With this computerized data we can detect any undesirable changes of the cornea caused by wearing contact lenses. A second test uses the microscope to examine the fit of the contact lens and the health of the cornea. Thirdly, prescription measurements are done which can be different than those for glasses.

Isn't this part of my annual eye exam?

These contact lens-related tests are done in addition to the eye examination. These are procedures that only need to be done for contact lens wearers, not for patients who don't wear contact lenses.

How much does it cost?

Depending on the type of lenses you wear the cost for the professional services can vary ($80 - $310). The office staff will be able to give you the exact cost for the lenses that you wish to wear.

Doesn't my insurance cover contact lens professional fees?

It depends on your plants coverage. Most insurance plans cover a routine eye exam which determines your glasses prescription and evaluates your eye health. Contact lens services are separate procedures that may be discounted or often not covered by insurance.