Refractive Services Global Fee Sheet Platinum Plan Custom wavefront technology iLASIK (laser used to make flap) or ASA -2 years follow up care including free enhancements for 5 years
$ ______
$2574 / eye
Gold Plan* Custom wavefront technology LASIK (with microkeratome) or ASA -1 year of follow up including free enhancements for 1 year
$ ______
$2074 / eye
Gold Value Plan* LASIK (with microkeratome) or ASA with traditional treatment -1 year of follow up including free enhancements for 1 year
$ ______
$1874 / eye
Silver Plan* LASIK (with microkeratome) or ASA with traditional treatment -6 months of follow up care and enhancements at $250 per eye for 1 year
$ ______
$1524 / eye
Bronze Plan* ASA with PTK treatment; nearsightedness under 3 diopters, no astigmatism treatment, pupils must be smaller than 6mm -3 months of follow up care, no enhancement coverage
$ ______
$499 / eye
Promotions or Insurance Discounts
$ ______
Exclusions
Your fee does not include: Prescription medications needed for your surgery Temporary glasses Punctal Plugs Emergency room visits Office visits unrelated to your surgery
TOTAL GLOBAL FEE This global fee includes pre and postoperative care* for specified follow up period, mono-vision diagnostic contact lens evaluation and Moisture Eye drops (Artificial Tears). Enhancements will be billed after the follow up period at 50% of the current rate unless otherwise specified.
$ ______
$ ______ Down Payment
$250 Paid on
______
(date)
_______
Received by (initials)
$ _______
Via
________
Received by
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.
Via
TOTAL AMOUNT DUE ON DAY OF SURGERY
VISA, MASTERCARD, DISCOVER, Money Order, Cash or Financing. Cashier’s checks to “Beyer Laser Center”
PAYMENT MUST BE MADE IN FULL ON THE DAY OF SURGERY
NO PERSONAL CHECKS ACCEPTED
Diagnosis and Code:
Myopia (367.1)
Procedure: Laser Vision Correction (65760) OD Patient Name: Patient Signature: Witness Signature: Co-Managing Doctor (If applicable) :
Hyperopia (367.0)
Procedure Date:
OS
Surgeon:
OU
*This global fee also includes payment to co-managing doctor to perform all pre and post-operative exams, if applicable. TAX ID# 84-1513514
Date: Date: