Refraction Form

Refraction Service & Fee / Visual Field Screening Fee / OCT Wellness Photo Fee

This is part of our annual comprehensive eye exam. It is the procedure in which we determine the best corrected visual acuity of each eye for purposes of medical evaluation or for prescribing corrective eyeglasses, contact lenses, or corrective surgery. A change in refraction can be the first sign of eye diseases such as cataracts. Most medical insurance plans, including Medicare, do NOT cover refractions. Medicare allows that we charge separately for that portion of the examination, since it is not a covered service.

Every 3 years (date of last screening):

The visual field screening measures peripheral vision and screens for eye diseases and neurological conditions including glaucoma, brain tumor and stroke.

Every 3 years (date of last screening):

Wellness Imaging takes a picture of the inside of the eye and measures the thickness of the macula and optic nerve. It can detect early signs of eye diseases like macular degeneration and glaucoma.

These fees are collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly.

Patient Acknowledgement

I have read the above information and understand that the refraction/Visual Field Screening/OCT Wellness photo is a non-covered service. I accept full financial responsibility for the cost of this service and understand it is due at time of service. I understand that any co-payment, coinsurance, or deductible I may have, are separate from, and not included in, the refraction fee.

Patient Name (Parent for Minor)


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