Please read the information below. You will be asked to sign a copy upon arrival.

IMPACT RESISTANCE: Polycarbonate ophthalmic lenses provide the most impact resistance for your eyeglasses although plastic CR39 lens impact resistance is very good as well. The least impact resistance lenses are glass.

ORAL ANTIOXIDANTS: Oral antioxidants are recommended daily for everyone and are especially helpful for (1) those with light colored eyes, (2) those working outdoors and susceptible to UV light, (3) those with a family history of macular degeneration, and (4) those with cataract development.

PATIENT AUTHORIZATION: I authorize the release of any information necessary to process a health insurance claim, and authorize payment of insurance benefits to MONTANA EYECARE. I am responsible for any balance not paid by insurance, which may be sent to a third party agent for collection of any outstanding balance.


Dilation is recommended during eye examinations. Dilation is a procedure using eye drops to dilate (open) the pupil of the eye for the most complete internal eye inspection. The dilation usually lasts about 3 hours and also causes you to be light sensitive (sunglasses are provided) and blurs your near vision. Distance vision and driving are not a problem for most people. If you feel your driving vision is a problem, let our staff know so we can assist you in this regard.

An annual dilation of the eyes is especially important for patients with diabetes, glaucoma, cataracts, flashes and/or floaters, hypertension, high myopia or retinal problems. Patients over 40 years of age, on certain medications, with unexplained vision loss or with a family history of one of these problems should also have an annual dilation.



Notice of Possible Medicare Necessity

Denial for Eyeglasses and Patient Authorization

Medicare will only pay for services that it determines to be "reasonable and necessary," and will deny payment for any other services.

Medicare is likely to deny payment for:

•Anti-reflective coating •More than one pair of glasses after cataract surgery •Lens tints
•Scratch resistant coating •Wide segment multifocal lenses •Progressive multifocal lenses