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Panther Creek

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    NOTE: If Medicare doesn’t pay for (D)(*) below, you may have to pay.
    Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D)(*)below.
    (D) (E) Reason Medicare May Not Pay: (F) Estimated Cost:


    • Medicare will not pay for the refraction part of an eye exam. Anything not covered by Medicare becomes the patient’s responsibility unless the service is covered by a supplemental insurance.
    • $39.00

    • OCT Scan done same day as Optomap digital photos with same diagnosis. We discount the OCT Scan to $25.00 to avoid an additional office visit charge.
    • Medicare will not allow OCT Scan and Photos to be billed same day.
    • $25.00


      • Read this notice, so you can make an informed decision about your care.
      • Ask us any questions that you may have after you finish reading.
      • Choose an option below about whether to receive the (D)(*) listed above.

    Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

  • (H) Additional Information:

    This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
    Signing below means that you have received and understand this notice. You also receive a copy.

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    Form CMS-R-131 (03/08) Form Approved OMB No. 0938-0566
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