Patient Information

Insurance FAQ

  • Do you participate with my insurance plan?
    • Tri-Century Eye accepts a variety of insurance plans for both medical eye examination coverage and routine eye health examinations.
  • What is a medical examination?
    • A medical exam is performed if you have an eye-related medical problem, such as an eye injury, pink eye, double vision, headaches, cataract, dry eyes, glaucoma, or issues related to diabetes or high blood pressure (among many others). In these cases, your medical insurance will be billed for the medical eye exam. Your medical insurance co-payments and deductibles prevail and must be paid at the time of your examination. If your medical insurance requires co-insurance (meaning that you pay a percentage of the charges even after your co-pays or deductibles are met), you will receive a statement from us after your visit. Remember, if we do file the medical exam with your medical insurance, you can still use your Vision Plan benefits toward the purchase of glasses or contact lenses, based on your plan and allowances. At times it can seem like a complicated process, but these are the rules set by the insurance companies. We would be happy to answer any questions that you may have about your coverage.
  • What is a routine eye health examination?
    • As part of a routine eye health exam, our doctors examine your eyes for routine eye health and to determine the need for glasses (refraction) or other refractive correction. It is important that you understand that your Vision Plan (VSP, Superior, Davis Vision, EyeMed, etc.) covers ROUTINE well-care exams only, which includes the refraction to determine your eyeglass prescription. Your plan may also provide discounts or allowances toward eyeglass frames, lenses, or contact lenses. If a medical eye condition is known, or discovered during this eye health exam, a separate exam must then be made to address these issues and will be filed under your medical insurance. If your routine eye health examination reveals a medical condition or disease which requires special testing or follow-up care, the testing and subsequent examinations will be billed to your medical insurance as these are NOT COVERED by your Vision Plan.
  • What if I have a specific eye or vision complaint related to a new or pre-existing eye condition?
    • It is important to know that if you have a specific eye or vision complaint which is related to a new or pre-existing condition, such as cataract, glaucoma, diabetes, dry eyes, etc., or if you are here for a follow up appointment for a pre-existing condition as requested by a doctor, then your visit is NOT COVERED by your Vision Plan and will be billed to your medical insurance. Unfortunately, the doctor cannot always be sure whether a complaint such as decreased vision is related to a medical eye condition until after you are thoroughly examined.
  • Can you bill my other insurance company?
    • Once your exam has been filed with your insurance provider (at the conclusion of your visit) we CANNOT ALTER or CHANGE your examination documents or diagnosis codes or bill the other insurance.
  • When do I need a referral for my visit?
    • When you have medical coverage through an HMO, a referral is required to see our physicians for medical visits. For these patients, lack of the appropriate referral at the time of the appointment will necessitate payment in full at the time of the visit. If this is not possible, a re-scheduled appointment within a reasonable time frame will be made to accommodate your referral acquisition from your primary care physician.
  • Does my insurance cover prescription eyeglasses and contact lenses?
    • It is important that you understand that your Vision Plan (VSP, Superior, Davis Vision, EyeMed, etc.) may also provide discounts or allowances toward eyeglass frames, lenses, or contact lenses. Our optical and optometry staff will assist you in determining your benefit.
  • Still unsure about your medical and vision insurance?
    • As always, we are available to answer questions that you may have regarding your insurance coverage. You may direct your inquiries to our Insurance and Billing Department by calling 215-396-4211 between 8:00 a.m. and 4:30 p.m. Monday through Friday.

Patient Forms

To expedite your appointment registration process, please click on the New Patient Packet below to download the registration forms. After completing the forms, mail or fax them to our main office as listed below.

If your appointment is within one week, please fax the completed forms to our office or bring them with you at the time of your appointment.

Mail to:
Tri-Century Eye Care
319 Second Street Pike
Southampton, PA 18966

Fax to: 215-355-0790

Notice of Privacy Practices

Tri-Century Eye Care, P.C.
Effective January 1, 2021



At Tri-Century Eye Care, P.C., we are committed to using your health information responsibly.  This Notice of Privacy Practices describes the nature of your protected health information ("PHI"), and how and when we use or disclose that information.  It also describes your rights as they relate to your PHI.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential.  This Act gives you, the patient, the right to understand and control how your PHI is used.  HIPAA provides penalties for covered entities and Business Associates that misuse personal health information.

As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.


Protected health information is any information that relates to your past, present, or future physical or mental health or condition, including treatment and payment for services.  Each time you come to our practice, we create a record of your visit. Typically, this record contains information about your personal demographics, medical exam, diagnoses, test results, treatment, and other pertinent data.  Understanding what is in your health record and how your health information is used helps you ensure its accuracy, determine what entities have access to your health information, and make an informed decision when authorizing the disclosure of this information to other individuals.


Our practice is required to:

  • Maintain the privacy of your health information and use, disclose, or request such information only to the extent minimally necessary to accomplish the intended purpose of the use, disclosure, or request.
  • Provide you with this Notice and abide by its terms.


  • Treatment
    Your health information may be used by the staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, providing treatment, and coordinating your care.  An example of this would include referring you to a retina specialist.
  • Payment
    Your health plan (or other third-party payer) may request and receive information on dates of service, services provided, and the medical conditions(s) being treated in order to make payment, confirm coverage, billing or collection activities and utilization review under the relevant insurance policy.  An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
  • Regular Health Operations
    Your health information may be used, as necessary, to support the day-to-day activities and management of our practice.  These activities include, but are not limited to, quality assessments, employee training and reviews and other business and health operations.  An example of this would be new patient survey cards or a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.  We may also call you by name in the waiting room when your physician is ready to see you.
  • Business Associates
    In some instances, we have contracted separate entities to provide services for us.  These "business associates" require your health information in order to accomplish the tasks that we ask them to provide.  Some examples might be a billing service, answering service, or computer software provider.  They are required to treat your PHI in the same manner that we do.
  • Communication with Family
    Due to the nature of our field, we will use our best judgment when disclosing health information to a family member or any other person that is involved in your care or that you have authorized to receive this information.  Please inform the practice when you do not wish a family member or other individual to receive your health information.
  • Research/Teaching/Training
    We may use your health information for the purpose of research, teaching, and training.
  • Healthcare Oversight
    Federal law requires us to release your information to an appropriate health oversight agency, public health authority, or other federal or state appointee if there are circumstances that require us to do so.
  • Public Health Reporting
    Your health information may be disclosed to public health agencies as required by law.
  • Law Enforcement
    The practice may also disclose your PHI for law enforcement and other legitimate reasons although we shall do our best to assure its continued confidentiality to the extent possible
  • Appointment Reminders
    The practice may use your information to remind you about upcoming appointments by phone or in writing.  Typically, a brief, non-specific message will be left on your answering machine.
  • Fundraising Communications
    We may contact you, by phone or in writing, to provide information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you.  You do have the right to "opt out" with respect to receiving fundraising communications from us.

We may also create and distribute de-identified health information by removing all reference to individually identifiable information.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

  • Most uses and disclosure of psychotherapy notes;
  • Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
  • Disclosures that constitute a sale of PHI under HIPAA; and
  • Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.


You have certain rights under the federal privacy standards with respect to your PHI.

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you.  We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask.  If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
  • The right to receive confidential communications of PHI from us by alternative means or at alternative locations.
  • The right to inspect and copy your PHI.
  • The right to amend your PHI.
  • The right to receive an accounting of disclosures of your PHI.
  • The right to obtain a paper copy of this notice from us upon request.
  • The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you paid for services "out of pocket", in full, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

This notice is effective as of January 1, 2021 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect.  We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain.  We will post and you may request a written copy of the revised Notice of Privacy Practice from our office.

For More Information or to Report a Problem

If you have questions, complaints, or would like additional information regarding this notice or our privacy practices, please contact:

Privacy Officer
Tri-Century Eye Care, P.C.
319 Second Street Pike
Southampton, PA  18966

If you believe that your privacy rights have been violated, please contact the aforementioned Privacy Officer for Tri-Century Eye Care, P.C.  You may also file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services.  There will be no retaliation for filing a complaint with either the practice's Privacy Official or with the Office for Civil Rights.

Notice of Nondiscrimination & Accessibility

Tri-Century Eye Care, P.C. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Tri-Century Eye Care, P.C. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Tri-Century Eye Care, P.C.:

  • Provides free aids and services to people with disabilities to communicate effectively with us, including, but not limited to, qualified sign language interpreters.
  • Provides free language services to people whose primary language is not English, including, but not limited to, video remote interpreting services.

If you need these services, click here to see the contact information for your local division. 

If you believe that Tri-Century Eye Care, P.C. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Officer, 319 2nd Street Pike, Southampton, PA 18966, phone 215-355-4428. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-215-355-4428.

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-215-355-4428。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-215-355-4428.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-215-355-4428.

Pennsylvania Dutch:
Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-215-355-4428.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-215-355-4428 번으로 전화해 주십시오.

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-215-355-4428.

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 4428-355-215-1 (رقم هاتف الصم والبكم).

ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-215-355-4428.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-215-355-4428.

નોંધ: જો તમે પરંપરાગત ચાઇનીઝનો ઉપયોગ કરો છો, તો તમે મફતમાં ભાષા સહાય મેળવી શકો છો. કૃપા કરીને 1-215-355-4428 પર કૉલ કરો.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-215-355-4428.

French Creole:
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-215-355-4428.

ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-215-355-4428 ។

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-215-355-4428.

Terms & Use

The professional staff of Tri-Century Eye Care, P.C. has made every effort to provide accurate, up-to-date medical and scientific information. The content on this web site is not intended to replace consultation with an ophthalmologist or optometrist. Treatments and associated risks and benefits are intended for general educational purposes only and do not necessarily represent the only or best treatment options. By using any or all of the information contained in this web site, the viewer willingly assumes all risks in connection with such use. Neither the authors, physicians, company, or references cited shall be held responsible for errors, omissions in, or misuse of information herein, nor be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer’s use or reliance upon this material.

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