Payment Policy

If you prefer, you can print a hard copy of this form and fax it to 561-981-8460..
Payment Policy, Privacy, and Exam Information

Payment Policy

At CLVC, we are committed to providing you with the best possible care. We always strive to serve the best interest of the patient, and that means helping you take full advantage of any medical or vision insurance benefits you may have. We will always discuss your proposed treatment, cost, and payment options in advance so you are fully aware of the scope and value of all services offered.

Payment for all services is due at the time of service. We accept cash, checks, Visa, MasterCard, and American Express credit cards. We will also assist in processing your insurance claim for reimbursement. When Medicare is the primary payer, we may accept assignment of insurance benefits. Any returned checks of outstanding balances older than 30 days may be subject to additional collection fees and interest charges.

Please review the following details regarding insurance contracts:

  1. Your insurance status is a contract between you, your employer (if applicable), and the insurance company. We are not a party to that contract.
  2. Our fees are generally considered to fall within the acceptable range for most insurance companies and are therefore covered up to a designated maximum allowance that varies by each carrier (e.g. 50% or 80% of C.R). "U.C.R" is defined as usual, customary, and reasonable fees for this region. This statement does not apply to companies who reimburse based on an arbitrary "schedule" of fees, which bears no relationship to the standard and cost of care in this area.
  3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. For example, Medicare does NOT reimburse for refraction testing, which is often a necessary component of a medical eye exam. Therefore, you may be responsible for payment at the time of service for this and other charges.
  4. "Medicare assignment" does not mean Medicare pays in-full for all services rendered. Medicare will pay 80% of only approved services, so patient is responsible for any outstanding balance, usually 20%. Please understand that our professional relationship is between you and Dr. Cohen, not the insurance company. Therefore, all charges for services rendered are ultimately your responsibility to be paid when due.
  5. We recognize that there are financial problems which may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. Ultimately, payment issues will never interfere with the quality of your care.

If you have any questions about the above information or concerns about payment, please do not hesitate to contact us. We are here to help. Thank you for your understanding.

Kindly acknowledge acceptance of this policy by signing below:

Important Information Regarding Complete Eye Exams with Dilation

At CLVC, we strive to provide every new patient with a thorough diagnostic exam, which includes dilation. Dilation is necessary to properly assessing and evaluating all aspects of the eye, including tissues that are otherwise not accessible. While we understand that dilation can be a temporary impairment, it is generally required for all new patients desiring to establish care with us. Dilation takes time, so please allow 1-2 hours for a complete exam.

Dilation and other diagnostic measures may render your vision temporally blurry for this reason it is recommended that all new patients come with a driver. Sensitivity to light and decreased near vision are reasons many do not feel safe operating a motor vehicle. Please use your discretion and do not attempt to drive if you do not feel comfortable. Sunglasses or shades will be provided for the 2-4 hours your vision may be sensitive to light. Other rare complications that may result from pharmacologic dilation include acute glaucoma, arrhythmia, dizziness, elevated blood pressure, and others which may occur despite appropriate precautions. Any drastic change in vision, redness, or pain requires immediate medical attention. The risks and benefits of dilation will be discussed at the time of your visit, and exceptions will be made in consultation with the physician. Keep in mind any adverse reaction to dilation is extremely rare.

I hereby authorize my eye doctor and/or such assistant he/she may designate to administer dilating eye drops if recommended.

Important Notice to Parents and Legal Guardians:

I understand that my child's eyes may be dilated, this could impair his or her vision such that climbing, bike riding, and other activities could be potentially dangerous and should be avoided until vision returns to normal. Additionally, I hereby give consent to any additional examinations and/or treatment necessary for my child's condition.

Fee Schedule for Refraction


Refraction is the technical term for the process of determining the amount of corrective eyeglass power required to obtain your best vision. The physician believes this is an important component of your medical exam and recommends this test be performed. It is customary in the field of ophthalmology to perform a refraction if indicated and to charge for the service, as often insurance does not reimburse the practice for this type of testing. 

Fee Schedule:

  • Refraction for glasses $60.00
  • New contact lens fit (never worn contacts) $150.00
  • Contact lens change (update) $75.00

Contact lens fittings include a short trial of lenses that may need to be shipped in certain circumstances. This fee does NOT include the cost of lenses themselves, which are ordered when the refraction is finalized through the patient's preferred vendor.


These fees will be collected at the conclusion of your visit. As a courtesy, we will bill your insurance if applicable for this service. if your insurance company indeed does pay for the refraction, a prompt refund or future credit will be reimbursed. Thank you for your cooperation and understanding in this matter.

To ensure the privacy of our patients, please complete the following

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned by my signature. This authorization shall be in effect until l revoke such disclosures.