May we leave messages/detailed medical information on voicemail at either of these phone numbers?

If YES, please complete:

I hereby authorize Wyomissing Optometric Center physicians and staff to obtain or release any and all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment to or from any other health care providers, laboratories, imaging facilities, or other institutions.

• This authorization remains in effect until revoked

I have reviewed the aforementioned information and provide my consent regarding any and all issues as stated above. I have reviewed the Wyomissing Optometric Center HIPPA PRIVACY POLICY. A copy of this policy will be provided to me upon request.

MEDICAL/MEDICARE PATIENTS

Provider ID: EY426305

**The following notice applies to all general medical insurance including Medicare**

Medicare will only pay for service that it determines to be "reasonable and necessary" under section 1862 (a) (1) of the Medicare Law. If Medicare determines that a particular service, although it would be otherwise covered, is not "reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service.

I believe that, in your case, Medicare is likely to deny payment for:

CONTACT LENS PATIENTS

Please be advised that as part of a contact lens evaluation for established or new patients, our practice requires topographical mapping of the coreneal surface as a baseline and to assure that there is no change in corneal shape from the contact lens wear. Unfortunately, many insurance companies or vision care plans do not provide reimbursement for this testing. Additionally, our office provides 6 months of follow up care during the fitting period for NEW contact lens wearers, in addition to a visit to instruct our patients on insertion, removal, and appropriate care for contact lenses. The fees for these services are NOT covered and are the responsibility of the patient. These fees can range from $75.00 - $150.00 for cosmetic contact lenses.

I am aware that the non-covered fee for contact lens related procedures will be discussed with me prior to any contact lens related testing and that I will be fully responsible for those non-covered service fees.