Retinal Health and Nutrition Screening Form Medicare

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

Allisonville Eye Care Center continues to offer advanced vision care, and we know that our patients want technology that safeguards their eye health. We now perform two important screening tests at your annual eye examination. (non-diabetics only) These tests are not covered by insurance plans, but we have reduced the copay as shown below. WE ARE ASKING YOU TO COMPLY WITH THIS PROTOCOL DUE TO THE COVID PANDEMIC TO REDUCE CLOSE CONTACT WHILE ENABLING THE BEST EXAMINATION.
1) OptoMap Screening Retinal Imaging- to see the inside of your eye

The Optomap is a fast and non-invasive technique to capture an essential view of the retina to help uncover ocular diseases like macular degeneration, glaucoma, diabetic eye disease, hypertension, and eye cancer. If these conditions go undetected, they could lead to vision loss and ultimately blindness. If you elect to have an Optomap, the Doctor may not need to dilate-but dilation does NOT replace the advanced view available with the Optomap.

2) 2 NEW FOR 2020: Skin Carotenoid Scan- Macular Pigment/General Nutrition Status

Macular Pigment (MP) in the back of the eye is essential for clear vision and protection from eye disease. In fact, patients with the highest vs. lowest levels of MP are 82% less likely to develop macular degeneration the number one cause of vision loss at age 55 and above. Research-backed technology allows us to evaluate your MP level and general nutrition status with a 30-second scan of your hand.
- Due to COVID-19: Retinal Health and Nutrition Assessment is essential to provide a more thorough exam with less close contact. THE COPAY INCLUDES BOTH TESTS-NOW REDUCED TO $38.
- CHECK HERE IF YOU ARE DIABETIC- and understand that we will perform medical photography instead of Optomap Screening that will be billed to medical insurance subject to any copay and deductible. Your eyes will still be dilated after discussion with the doctor.
- Diabetics, please check here to have the Skin Carotenoid/Macular Pigment Screener for $10.
- I choose to decline this Retinal Health and Nutrition Assessment.
- Uncertain- I would like more information from the Doctor.
For Medicare Patients: Medicare does not pay for all your health care costs. Medicare only pays for covered benefits. 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.

The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you will have to pay for them yourself. Before you make decision, please ask questions for clarification.
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