Annual Renewable Plan

If the ophthalmologist recommends Retreatments subject to the conditions described below, you will only have to pay the licensing fee charged by the laser manufacturer You will not have to pay any facility fees, provider fees, or other fees. To keep this Provider Retreatment Plan in place you must have an annual eye exam scheduled through the QualSight Care Management Center. Retreatments are done at the discretion of the participating ophthalmologist. This Plan is subject to the following conditions:

1. If your ophthalmologist recommends Retreatments and uses Nidek equipment, there is no charge. Otherwise, if a Retreatment is required, you agree to pay $110 to $300 per eye licensing fee for all laser manufacturers which is subject to change without notice. You will not pay any additional fees to the participating provider or facility at which the Retreatment is performed. The Retreatment can only be performed by the practice who performed the original procedure and at the discretion of the ophthalmologist.

2. Every twelve months following your initial laser vision correction procedure, you have an opportunity to extend this Retreatment Plan by having an annual exam performed by the same provider that performed your procedure. The fee for this exam is currently set at $80.00 (price may change without notice). This Retreatment Plan will become void if you do not schedule the Retreatment exam through the QualSight Care Management Center each year following your laser vision correction surgery.

3. Retreatment exams must be scheduled through a QualSight Care Manager. To schedule the Retreatment exam a non-refundable exam fee will be collected by QualSight. You may reschedule the appointment with a minimum notice of forty-eight hours.

4. QualSight’s records of the dates of the Retreatment exam and eligibility within the twelve month post procedure time shall be final in determining applicable dates.

5. You will be responsible for any taxes or charges imposed by any governmental agency with respect to the Provider Retreatment Plan.

6. The ophthalmologist's medical opinion is final in determining if Retreatments may be performed and failure to follow the provider's advice with respect to eye health and general medical care may void this Provider Retreatment Plan.

7. The Provider Retreatment Plan is based on existing laser technology which was used to perform your LASIK. It does not cover other ocular occurrences unrelated to the LASIK procedure, which may cause changes in the patient's vision. These include, but are not limited to, corneal ectasia, keratoconus, corneal opacities, lens changes (cataract formation) which leads to increased myopia, hyperopia, or astigmatism.

8. QualSight administers the vision correction services and is not licensed to provide and does not provide such services. Services are provided solely by a licensed provider who is not an employee of QualSight. QualSight does not warrant, guarantee or otherwise make any promises with respect to the vision correction services of a Provider’s ophthalmologist including the outcome of any vision correction services provided by a Provider’s ophthalmologist.

Provider Participation may vary.