Notice of Exclusion Form

Phone: <a class="ecp-phone-call-phone" href="tel:317-577-0707" style="text-decoration:none"> 317-577-0707
Email: allisonville.eyecare@gmail.com (Do not send personal health information by email.)

Name: Allisonville Eye Care Center
Address: 10967 Allisonville Rd Ste 120, Fishers, IN, 46038, US
Telephone: 317-577-0707
Price range: $000 - $300

Medicare does not pay for all your health care costs. Some items and services are not Medicare benefits, and Medicare will not pay for them. When you receive an item or services that is not a Medicare benefit, you are responsible to pay for it, personally or through any other insurance that you may have.

We believe in giving you the best care and most comprehensive eye exam, therefore we perform a REFRACTION for every annual exam. This helps us monitor changes in your vision while also providing you with the most accurate glasses/contact lens prescription. Medicare does not cover the refraction and a charge of $69.00 will be collected at check out.
Please acknowledge that you understand by signing below
Patient Name
This field is hidden when viewing the form
Date
MM slash DD slash YYYY
Patient/Guardian Signature