EyePrint Pro ABN Patient Name:(Required) First Last Date(Required) MM slash DD slash YYYY ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) Notice of Pricing for the EyePrintPro™ Scleral DeviceWHAT YOU NEED TO KNOW:Read this notice, so you can make an informed decision concerning this lens option. Ask us any questions that you may have after you finish reading. If you want to pursue EyePrintPro™, you are responsible for payment, upfront at the time of service. EyePrintPro™ is a scleral device designed to match the exact contours of an individual eye, providing the best vision and comfort possible. There are a number of steps necessary to creating an EyePrintPro™, which are different from other contacts or scleral lenses. These include taking an impression of the ocular surface, advanced software design and custom optics, based on the individual eye.The costs for the EyePrintPro™ is $3665.00 per eye, for the impression and basic lens. Impression and fitting of device (92499): $1,150.00 / Eye EyePrintPro™ device (V2799): $2,515.00 / Device This Fee Includes:Impression of the ocular surface Mailing of the impression to the designer, scanning and fabrication of the EyePrintPro™ One remake of the EyePrintPro™ device within 3 months Office visits associated with dispensing and examination of the device This few does NOT include:Medical Office visits for routine examination of the device Replacement devices due to loss or breakage Upgrade add on features: Toric: $115.00 Multifocal: $465.00 Decentered optics: $465.00 Prism: $650.00 Warranty: Breakage, loss, spare, etc. within 6 months: $1,550.00 Breakage, loss, spare, etc after 6 months: $1,850.00 Cancellation fee: 50% refund of device charge No refunds on Professional fees (Required) I understand that by signing this form, I am responsible for the payment of this device. I will be asked to pay in full at the time of service.Signature(Required)Date(Required) MM slash DD slash YYYY Δ
