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Practice Location: San Jose, CA
Costco Sublease Disclaimer
☐ I understand that Senter iCare is an independent optometry practice operating under a sublease agreement within
Costco Wholesale
☐ Senter iCare is not owned, operated, or affiliated with Costco Wholesale Corporation
☐ All professional eye care services are provided solely by Senter iCare; Costco does not set, bill, or collect exam fees
☐ Questions regarding eye care services, billing, or medical records must be directed to Senter iCare, not Costco
Financial Policy – Cash Pay Only
☐ I understand Senter iCare is a cash-pay practice only
☐ Payment is due in full at the time of service
☐ Accepted payments include Cash, Credit/Debit Cards, and HSA/FSA cards
☐ Personal checks are not accepted
Insurance Policy
☐ Senter iCare does not bill vision or medical insurance
☐ No insurance claims, referrals, or prior authorizations are submitted
☐ A superbill may be provided upon request for patient self-submission
☐ Insurance reimbursement is not guaranteed and is solely my responsibility
Contact Lens Policy & Patient Responsibility
☐ I understand that contact lens exams, fittings, classes, evaluations, and follow-ups are not covered benefits under most insurance plans
☐ If I choose to be examined or fit for contact lenses, I am responsible for all professional contact lens service fees on the day of my exam
☐ All contact lens exams and follow-up visits must be completed within 90 days of the initial contact lens exam
☐ After 90 days, I am responsible for any additional contact lens fees, including fees for a new comprehensive exam if deemed medically necessary by the doctor
☐ I understand that monitoring the health of my eyes is the doctor’s responsibility and that a one-year expiration on my contact lens prescription may be medically necessary to prevent eye damage and promote proper contact lens compliance, including:
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Cleaning, handling, disposal and wearing schedule
HIPAA – Notice of Privacy Practices & Communication Consent
☐ I acknowledge that Senter iCare complies with HIPAA, a federal law protecting the privacy of my health information
☐ I understand my protected health information may be used or disclosed only as necessary for:
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Treatment, payment, healthcare operations, processing vision benefit information (if applicable)
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Appointment reminders and exam recalls
☐ I authorize Senter iCare to contact me via phone, mail, and/or email regarding appointments, recalls, or necessary communication
☐ I acknowledge that I have received or have access to the Notice of Privacy Practices
Patient Acknowledgment & Consent
By signing below, I confirm that I have read, understand, and agree to the financial, contact lens, privacy, and sublease policies above and accept full financial responsibility for services rendered.
Patient Full Name: __________________________________
Signature: _________________________________________
Date: _____________________________________________
Parent / Guardian (if minor): _________________________