Corneal Cross-linking Global Fee Global Fee This global fee includes pre and postoperative care* for 6 months, Riboflavin and UVB cross-linking treatment
This is not $ 1999.00/eye
The patient will bear all financial responsibility for all and any visits to another medical or eye care facility, excluding pre-approved comanagement care.
covered by medical insurance
Exclusions This fee does not include: Prescription medications needed for your surgery Moisture Eye drops (Artificial Tears) Punctal Plugs Office visits unrelated to your surgery Emergency room visits
These fees may be covered by your medical insurance
Subsequent PRK or LASIK surgery TOTAL GLOBAL FEE
$ 3998.00
$ ________________
Down Payment A down payment is due at time of scheduling. This fee will be applied to the surgery fee. If patient cancels surgery, fee is non-refundable.
$250
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Paid on (date)
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Via (pay method)
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Received by (initials)
TOTAL AMOUNT DUE ON DAY OF SURGERY
VISA, MASTERCARD, DISCOVER, Money Order, or Financing. If Cashiers Check, make payable to: Beyer Laser Center, LLC
PAYMENT MUST BE MADE IN FULL ON THE DAY OF SURGERY
NO PERSONAL CHECKS OR CASH ACCEPTED
$ _______3998.00_
Via Received by
Diagnosis and Code: Corneal Ectasia ICD-9-CM 371.71 Procedure: Corneal collagen cross-linking(CPT code 92499) OD OS OU
Date of Procedure:
Patient Name:
Surgeon Name:
Patient Signature:
Date:
Witness Signature:
Date:
Co-Managing Doctor (If applicable) : This global fee also includes payment to co-managing doctor to perform all pre and post-operative exams, if applicable. TAX ID# 84-1513514