Last Revised: April 16, 2018
A laser eye exam is not required. If you would like to obtain an exam follow these instructions.
Laser Eye Exam Instructions
1. Get authorization from your department’s Business Administrator or Financial Office. The cost of the
laser eye examination is ~$280.00.
2. Call 215-662-8100 to schedule an appointment.
3. Tell the scheduling representative that you need an eye examination for laser users.
4. The scheduling representative may ask you for your insurance information. Tell him or her that the University is
paying for the exam and you will be bringing the billing information on the day of the exam.
5. Download the Laser Eye Examination Form from the EHRS website.
6. Fill in the form as follows:
a. In Field 1 enter the name of the Business Administrator or Financial Office contact.
b. In Field 2 enter today’s date.
c. In Field 3 enter the patient’s name.
d. In Field 4 enter the name of the Business Administrator or Financial Office contact.
e. In Field 5 enter the address and mail code of the Business Administrator or Financial Office contact.
f. In Field 6 enter the phone number of the Business Administrator or Financial Office contact.
7. Print the form on department letterhead and have the Business Administrator or Financial Office contact sign it.
8. Take the signed form with you to your appointment. Ophthalmology will not perform the eye examination if you do not have the form with you or if it is incomplete.