Catalina Eye Care, P.C.
Lynn Polonski, M.D.
Ovette Villavicencio, M.D. Ph.D.
Leslie Weintraub, O.D.
3925 E. Ft. Lowell Rd. Ste 100
Tucson, Arizona 85712
PH: 520-576-5110
FX: 520-529-7165
INSURANCE ADVANCE BENEFICIARY NOTICE
(ABN)
*Insurance will only pay for services that it deems medically necessary. If my insurance determines that a particular service, although it would otherwise be covered, is not reasonable and medically necessary, they may deny payment for that service. For instance, your insurance may likely deny payment for:
- Refraction$50.00
- A-SCAN$90.00
- Topography$40.00
- OCT $45.00
- Pachymetry $25.00
- Pentacam $65.00
- Digital Retinal Image$39.00
Please read and sign the following statement:
Most Insurance policies pay only a portion of your total charges. If you have any questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies. Please understand that financial responsibility for your account is yours, not the responsibility of your insurance company. I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of services rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay.
Signed______
Date______
Witness______
Date______
CONTACT LENS SERVICES
Contact lens exams and evaluations are separate from your Complete Eye Exam, and they may not be covered charges under your insurance plan. The following is a list of charges:
CONTACT LENS CHECK: $50.00
Evaluation of fit and power of contact lenses currently worn
Initial_____
CONTACT LENS REFIT: $80.00
Refit and Prescription for the same brand of contact lenses currently worn with a new power and/or base curve.Trial pair of lenses and follow up care is included.
Initial_____
CONTACT LENS FIT: $100.00
Fit and Prescription for new brand/type of contact lenses. Trial pair of lenses and follow up care is also included.
Initial_____
SPECIALTY CONTACT LENS FIT: $150.00
Fit and Prescription for the following specialty lenses: TORIC, BIFOCAL, MONOVISION, and RIGID GAS PERMEABLE or HARD LENSES.
Trial pair of lenses (SOFT ONLY) and follow up care is also included.
KERATOCONUS CONTACT LENS FIT: $250.00
Initial_____
Decline to have Contact Lens Services
Patient does not wish to have a contact lens evaluation or services done.
Initial_____
Not Applicable
Initial_____
Patient Signature ______Date ______