DR. ARKADY SELENOW – DR. STEVEN ALI
160 EAST 56TH STREET – FLOOR 7
NEW YORK, NY 10022
TEL. (212) 688-4277
I understand that I am responsible for any co-payments that are linked to my examination and/or
glasses/contact lens benefit through my vision insurance.
I also understand that medical testing may be necessary and will be billed to my medical
insurance (e.g. diagnostic imaging and testing for ocular disease such as glaucoma, cataracts,
etc.) I understand that I am responsible for any co-payments, co-insurances, and/or yearly
deductibles that are linked to my medical insurance.
If I do not have separate vision insurance and my major medical does not cover the refraction
for my glasses, I understand that I am responsible for payment for the refraction and will be
The staff of MVA will explain your insurance coverage to the fullest extent possible. The
information we are given as providers from your major medical insurance is not a
guarantee. Ultimately, it is the responsibility of each patient to know the details of his