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Patient Forms


  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • Payment is due on the day of service. All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.
  • Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided. 1 will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3 % attorney fee will be due from me. Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.
  • We have a no return policy. All prescriptions glasses and contacts are made to order. We do stand behind our services.
  • Our office participates with both medical and vision plans. in the event that your exam is billed medically and there is a remaining balance, we will first exhaust your vision plan benefits before transferring any balance to your account. I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.
  • HIPAA Acknowledgement Receipt: The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy. (HARD COPY AVAILABLE UPON REQUEST)
  • Dr. Kartesz requires all his patients to have a retinal photo. He feels it is necessary to ensure proper diagnosis that can sometimes go undetected in a routine eye health exam. This test takes a 200 degree image of the back of the eye. In most cases, you will not have to be dilated today. The fee is $20.00. If the doctor finds a medical reason for the photo, we will bill your medical insurance.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY



Due to social distancing, we are first screening patients by phone for medical emergencies, prescription refills and other needs. If you have any questions, please contact our office and a staff member or doctor will help you.

Reordering Contact Lenses – we will gladly order and at no charge provide shipping so you do not have to make a trip to the practice. Just call the office to reorder, our friendly staff will assist you.

Picking up Eyeglasses – We offer CURBSIDE service, just call our office to make arrangement and we will gladly provide you with your new eyewear. If you prefer we ship them, we will do so free of charge.

We are here for you for all of your eyecare needs. Don’t hesitate to call our office.