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In the Capital Plaza Shopping Center in Austin
Important COVID-19 Office Safety Measures

Home » Find Us » Patient Forms » Exam, HIPPA, & Financial Responsibility

  • EXAM REQUESTED

    EXAM REQUESTED

  • Comprehensive (Dr. Recommended): Comprehensive exam includes a screening visual field when possible, and additional tests that allow the Dr. to perform a more thorough exam.

    If you are seeing a resent onset of "FLOATERS" or "FLASHES OF LIGHT", it will be necessary to dilate your eyes to rule out a retinal detachment. If you are DIABETIC, dilation is recommended annually. Most patients can drive after the exam however, your vision (especially near) will be impaired for 2-4 hours.

    If you are using insurance and you desire a comprehensive exam please inquire at the front desk to see if your insurance company will cover this level of exam.

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  • Contact Lens Fees below are ADDITIONAL to Exam Fees:

  • Multifocal and Toric fitting fee is $90.00

    New fit or refitting fee is $80.00

    Established annual contact lens evaluation and update is $50

    Contact lens instruction (insertion and removal) fee is $20.00

    *Contact lens cost is additional and varies by lens type and manufacturer.*

    Refraction fee NOT covered by Medicare, is $35.00

  • ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT (HIPPA)

    ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT (HIPPA)

  • I have been made aware of the HIPAA Privacy Practices Notice for Dr. Clark & Associate Optometrist, P.A/TSO/Texas State Optical Capital Plaza which is posted in the waiting room and went into effect April 14, 2003. A copy is available upon request.

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  • Financial Responsibility

    Financial Responsibility

  • I authorize release of any medical or other information necessary to process insurance claims. I also request payment of benefits (including any Government benefits) either to myself or if assignment is accepted, to Dr. Clark & Associate Optometrists, P.A. While we do our best to determine your out-of-pocket expenses at the time of service, we cannot be certain until your claim is paid by your insurer. At that time, we will bill you for any unpaid balance or refund any overpayments.

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