Patient Forms And Policies | See Clearly Vision Arlington

Forms And Policies

For Patients

Patient Forms

Our practice strives to provide you and your family the best possible patient experience. Please arrive a few minutes early so that our staff can meet you and properly gather your medical information.

Contact Lens Policies and Fees

Our doctors fit all types of contact lenses for common vision problems such as nearsightedness, farsightedness, astigmatism, and presbyopia as well as for the therapeutic treatment of certain eye diseases. 

Download our Contact Lens Evaluation Agreements below:

Refraction Fee Notice

There are two parts to your eye examination, which are billed separately.

The first charge includes the fee for the doctor to evaluate the health of your eyes. This charge is billable to your insurance company, and also to Medicare. The second (vision) portion of your exam is called a “refraction,” which is a test performed to determine the best corrective lenses to be prescribed for each eye.

Although a refraction is a very important vision test, it is considered a non-medical procedure. Medicare and most insurance plans do not pay for this service, the fee of which is $70.00, effective 1/30/23. We request that payment for this service be made at the time of your visit. Thank you.


Should you need to reschedule your appointment, we would ask for 24 hours notice.  We do charge $25 for all appointments rescheduled with less than 24-hour notice.

Emergency Care

During business hours, patients should call any of our office locations to speak with a staff member. After business hours, our answering service is available to route your call to a member of our on-call patient care team. Please note, any patient with a life-threatening medical emergency is advised to dial 911 to receive emergency medical care.

Records Release

To be compliant with federal regulations, medical records will be kept for seven years. After seven years, records will be properly disposed of in a manner which protects patient confidentiality. A patient may request a copy of their records for a nominal fee. You can submit your records release form by email at: or by fax at: 703-827-5539. Please allow up to 15 business days for delivery.

If you would like your records transferred from another doctor’s office to our practice, please contact their office to initiate the transfer. 

You may also request an amendment to your medical records:

HIPAA Notice Of Privacy Practices

At See Clearly Vision, we value the privacy of all of our patients. To review our privacy practices, click here. To complete our privacy practices acknowledgement form, click here.

Other Forms

Our Locations

Tysons Corner


8138 Watson St
McLean, VA 22102

Phone Number:



Monday through Friday
8:30 am to 5:00 pm



1715 N. George Mason Drive
Suite 206
Arlington, VA 22205

Phone Number:



Monday through Friday
8:30 am to 5:00 pm

Contact Us

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(703) 827-5454
(877) 234-2020
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