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
$ ______
$2524 / eye
Gold Plan* Custom wavefront technology LASIK (with microkeratome) or ASA -1 year of follow up including free enhancements for 1 year
$ ______
$2024 / 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 A down payment is due at time of scheduling. This fee will be applied to the surgery fee. If patient cancels surgery, fee is nonrefundable.
______
$250 Paid on (date) Via
_______
Received by (initials)
$ _______
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)
________
Hyperopia (367.0)
Procedure: Laser Vision Correction (65760) OD Patient Name: Patient Signature: Witness Signature: Co-Managing Doctor (If applicable) :
OS
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
Procedure Date: Surgeon: Date: Date:
Received by