Visual Information Processing Evaluation Explanation of testing, fees and billing procedures A Visual Information Processing Evaluation has been recommended to further investigate the visual deficits that are of concern. If you or your child has not had a comprehensive ocular health and skills assessment within 6 months of the request for a Visual Processing evaluation, it will need to be completed prior to this evaluation. Included in the testing is an evaluation of Visual Information Processing skills. The specific testing done is customized to each patient and may include evaluation of visual spatial skills, visual speed processing, hand eye coordination, gross motor and fine motor coordination and visual perception (the ability to visually compare and sort visual images including visual memory). Testing Includes: Visual Information Processing/Rehabilitation testing Consultation Comprehensive report The total fee for a Vision Rehabilitation/Visual Perceptual evaluation typically ranges from $250-$500. A portion of that fee may be billed to your insurance if we are providers for your plan.The perceptual evaluation cannot be billed to your insurance provider; it is not a covered service. Payment is needed in full at the time of the evaluation. It is your responsibility to know if your insurance covers the type of office procedures performed and whether referrals are necessaryAdditional information about this portion of the evaluation is included on a supplemental information sheet. I understand that I am responsible for all fees, referrals, co-pays, deductibles and non-covered procedures and devices provided. Name(print) First Last Date MM slash DD slash YYYY SignatureI authorize Shore Family Eyecare to submit to my insurance and assign the benefits to be directly paid to the doctors of Shore Family Eyecare when applicable. Name(print) First Last Date MM slash DD slash YYYY SignatureI understand that Shore Family Eyecare is fully compliant with HIPPA regulations and privacy issues. I request the professional records/ reports only be released to Shore Family Eyecare when necessary and to release my records to other doctors/ professionals who may provide care for me in the future. Name(print) First Last Date MM slash DD slash YYYY Signature
