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Raleigh Optometry, PLLC
Dr. Donathan Hudgins

Raleigh Optometry, PLLC
Dr. Donathan Hudgins

Home ยป Waiver of Liability Form

Waiver of Liability Form

  • There are services that Medicare and other insurances companies do not cover. It does not mean that these are not important services for you to have. It only means your insurance policy does not include them in coverage. Independent diagnostic procedures are considered to be those that go beyond the services included in a general ophthalmological exam or those in which special treatment is given. Most insurances companies only cover basic, routine examination procedures and do not have allowances for procedures beyond the basic service. These independent diagnostic procedures will be performed when they are deemed to be visually or medically necessary for the well being of the patient. Though your vision insurance may not cover these procedures, your major medical insurance may cover them.

    The following are examples of some of the services that are provided by Dr. Hudgins, that are, or may be considered non-covered by your insurance carrier. You will be expected to pay for these services at time of visit:
    • Refraction
    • Extensive visual field evaluation
    • Contact lens fitting
    • Foreign body removal
    • Eyeglass/Contact lens materials
    • Post surgical treatment & management
    • Oculomotor diagnostic exam
    • Vision perception exam
    • Extended ophthalmoscopy
    • Dry eye analysis & management
    • Fundus photography
    • Gonioscopy
    • Contact lens progress exam
    • Anterior segment photography

      I agree that I am personally and fully responsible for payment for these services and any other non-covered services I receive by Dr. Hudgins
    • Date Format: MM slash DD slash YYYY