Financial Disclosures

Patients, or the legal guardians of patients under the age of 18, are financially responsible for the full payment of any and all services provided. Valid credit or debit cards are required at every appointment. Copays and any outstanding balances will be collected prior to all appointments.

Rhode Island Eye Institute will keep each patient's credit card authorization information on file. Should there be a patient balance post‑insurance adjudication, the patient's card will be charged for the outstanding balance.

Medical Eye Exam

A medical eye exam is related to an eye complaint or pre‑existing condition. This includes previous medical diagnoses such as cataracts, glaucoma, diabetes, thyroid eye disease, Plaquenil toxicity, and similar conditions.

It also includes visits for eye‑related complaints such as eye discomfort, redness, tearing, or other symptoms that require a medical evaluation.

Routine Eye Exam

• Performed every year or every other year.
• No pre‑existing eye condition is present.
• General eye health check with no eye complaints.
• No diagnostic testing is performed with this type of visit.

I acknowledge that I have read the above and fully understand the difference in nature of the exams. I understand that asking my physician to withhold a diagnosis would be committing insurance fraud.

I also understand that, ultimately, it is the doctor's decision how my claim will be billed, based on the findings of my exam and not based on my insurance coverage.

Vision Plan Participation

Our Maryland offices do not participate with any vision plans.

Our RI, PA, NJ, and some of our CT clinics do accept vision plans.

In locations that do not accept your vision plan, or if you do not have vision coverage, routine coverage must be through your medical insurance policy.

The refraction is the part of the exam in which Rhode Island Eye Institute Eye Health checks to see if you need a new eyeglass prescription. Medicare and some other medical insurance companies do not pay for this service.

Should a refraction be needed at this visit or at a future visit, in discussion with your doctor, an additional fee may be charged for this service. Charges for additional screening procedures may also apply.

Before the exam, we will inform you of any additional charges related to a refraction and any other procedures that you elect to have performed.

In locations that do not accept your vision plan, or if you do not have vision coverage, routine coverage must be through your medical insurance policy.

I authorize Rhode Island Eye Institute Eye Health to receive all insurance payments from my current medical insurance plan.

I agree to pay applicable co‑payments, deductibles, and non‑covered fees at the time of service, or upon first notification.

If my plan requires a prior approval or referral, I accept responsibility for all payments for non‑approved and/or non‑referred charges.

I agree to release all information necessary for my current insurance plan to process my claims.

I agree to pay in full at the time of service if I do not have insurance or choose not to have my insurance filed by your office.

Our goal is to provide excellent care to each patient in a timely manner. To do this, we ask that you inform us if you are unable to attend your scheduled appointment so that we can offer that time to another patient in need.

If you need to cancel or reschedule your appointment, please call at least 24 hours before your scheduled appointment.

You may incur a $50.00 cancellation fee if you cancel or reschedule less than 24 hours before your scheduled appointment (late cancellation) and/or fail to arrive at the designated date and/or time of your appointment (missed appointment).

Cancellation fees are billed directly to you (the patient), not your insurance, and are due prior to your next scheduled visit.

*Fees are subject to change. Bounced checks are subject to a service fee.*

With your help, we can continue to provide quality care and an exceptional experience to all of our patients in need of an appointment. Thank you!