NORTH DALLAS EYE ASSOCIATES

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1 NORTH DALLAS EYE ASSOCIATES W. Stephen Ku, M.D. Steven L. Elieff, M.D. Russell W. Snook, M.D. R. Raj Gupta, M.D. Eye Physicians and Surgeons PATIENT INFORMATION Last Name First Name MI Sex (Circle One) M F Street Apt # City State Zip Home Phone # Work Phone # Cell Phone # ( ) ( ) ( ) Address Marital Status DOB (mm/dd/yyyy) SSN # Employer Preferred Language Ethnicity Race EMERGENCY CONTACT Name Relationship Contact Phone # INSURANCE INFORMATION ( ) We will file your claim for covered services with only the insurance companies our doctors are contracted with. IF YOU HAVE AN HMO INSURANCE, YOU MUST HAVE A REFERRAL; OTHERWISE YOU WILL BE RESPONSIBLE FOR THE CHARGES. Please supply us with your insurance card(s) and driver s license so we may make a copy of them. If your insurance is through someone other than yourself, please complete this section: Primary Insurance Secondary Insurance Tertiary Insurance Primary Insured s Last Name First Name MI Sex (Circle One) M F Street (If Different) Apt # City State Zip Employer DOB (mm/dd/yyyy) Relationship SSN IF THE PATIENT IS A MINOR, PLEASE COMPLETE THIS SECTION: Father s Name (Last, First) SSN Father s DOB (mm/dd/yyyy) Employer Contact Phone # ( ) Mother s Name (Last, First) SSN Mother s DOB (mm/dd/yyyy) Employer Contact Phone # ( ) IF ONE PARENT IS AT A DIFFERENT ADDRESS, PLEASE COMPLETE THIS SECTION: Name (Last, First) Contact Phone # ( ) Street Apt # City State Zip

2 CONSENT TO TREATMENT I consent to the examination of my eyes by the physicians of North Dallas Eye Associates. I realize and understand that my eyes may be dilated for the examination. I realize and understand the potential risk to myself and others if I try to drive a vehicle or operate heavy machinery while the dilating drops are affecting my eyes. I realize and understand that the dilating may last from several hours to two days. I realize and understand that I may not be able to read while the dilating drops are affecting my eyes. I realize and understand that the dilating drops may affect my depth perception / ability to judge distances, and that even walking may cause some risk to me as far as judging the distance of things, (i.e. tripping over items or running into things). PAYMENT POLICY AND CONSENT FOR PAYMENT The practice of North Dallas Eye Associates strives to provide comprehensive, ethical and cost-effective eye care for our patients. In order for us to continue this mission, we have instituted the following policy. If you do not understand these policies, please ask our staff to explain before you are seen. 1. We will file insurance only with plans the doctors are contracted with. All insurance co-payment and/or deductible amounts are due at the time of the service. Any disallowed amounts are due from the patient. 2. We will not file insurance for our indemnity patients. Payment is due at time of services. 3. Your insurance policy is a contract between you and your insurance company. It is important that you understand what physician services are and are not covered, before seeing your doctor. There is no guarantee of payment of your claims, by your insurance company. Reduction or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred. If any portion of your claim or any service is not covered by your insurance, you will be responsible. For example, routine eye exams, goniosopy, therapeutic contact lens, fundus photos, or HRT. 4. Referral Authorization for HMO and other managed care plans must be obtained prior to your visit. If a referral is not received at the time of the visit, the patient is responsible for payment when services are rendered. I understand that I am responsible for all charges not paid by my insurance company(ies). I consent to pay for these charges in a timely manner in accordance with office policy. I am also responsible for all charges incurred by the office in collecting on my account if my bill goes unpaid, including but not limited to collection agency fees, attorney fees, and court costs. I authorize the release to my insurance company(ies) any information acquired in the course of my examinations, treatments, or surgeries. I authorize direct payment by my insurance company(ies) to Dr. Ku, Dr. Elieff, Dr. Snook, Dr. Gupta, WSK Eye Associates, P.A., or the North Dallas Eye Associates. I authorize that a copy of the below signature for insurance purposes is a valid as the original. NOTICE REGARDING NONCOVERAGE OF EYE REFRACTION Most insurance companies and Medicare, under section 1862 (a) (1) of the Medicare Law, will not pay for eye refractions (the procedure used to determine eyeglass prescriptions) because it is considered to be a routine service. If you choose to have a refraction performed, we will collect this amount at the time of your visit. I have been notified by the North Dallas Eye Associates that most insurance companies and Medicare will not pay for eye refraction services and agree to be personally responsible for this charge. CERTIFICATION OF INFORMATION Any person knowingly and with intent to defraud or deceive with incomplete or misleading information is guilty of a crime. I hereby certify that the information furnished by me in support of the above information is true and correct to the best of my knowledge. Signature (Patient or Legal Representative) Witness Date Date

3 NORTH DALLAS EYE ASSOCIATES W. Stephen Ku, M.D. Steven L. Elieff, M.D. Russell W. Snook, M.D. R. Raj Gupta, M.D. Eye Physicians and Surgeons NOTICE REGARDING EYE REFRACTION REFRACTION POLICY REFRACTION is a diagnostic test to determine your best corrected vision. This test can also be used for an EYEGLASS / CONTACT LENS PRESCRIPTION. It is an essential part of an eye examination, but usually NOT a covered service by Medicare or most insurance companies. This test is required by your insurance company as necessary documentation to evaluate for possible CATARACT SURGERY. Our office fee for refraction is $40.00 and this fee is collected in addition to your co-pay at the time of service. We will not file the eye refraction with your insurance company. You may file directly with your insurance company with your check-out receipt. ACKNOWLEDGMENT I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service. The co-pay is separate from, and not included in, the refraction fee. Patient Name (Printed) Patient Signature (Parent/Guardian for minor) Do you want to have refraction service today? Signature Date 1. YES NO 2. YES NO 3. YES NO 4. YES NO 5. YES NO 6. YES NO 7. YES NO 8. YES NO 9. YES NO 10. YES NO 11. YES NO 12. YES NO

4 NORTH DALLAS EYE ASSOCIATES W. Stephen Ku, M.D. Steven L. Elieff, M.D. Russell W. Snook, M.D. R. Raj Gupta, M.D. Eye Physicians and Surgeons INSURANCE POLICY We have contracted with many insurance carriers or managed care networks to be providers on their plan. Contractually, both the provider and the patient have certain obligations under these plans. 1. All insurance co-payment and/or deductible amounts are due at the time of the service. We will not bill you for your co-payment. A co-payment will be collected on every visit, even for follow-up visits. 2. We will ask for a copy of your current insurance card at each visit. Insurance companies often have various addresses and phone numbers, and they often change. Giving us a copy of your card at each visit helps us to confirm that all of the important details are correct. If we do not have proof of a valid insurance, we will hold the patient responsible for the full amount of the services. The insurance discounted fees will not be applicable in these circumstances. 3. We charge the insurance carriers our normal fees. We are paid their allowable amounts, and write off the difference between those two amounts as the provider discount. We DO NOT write off amounts that have gone to the deductible, noncovered services, or co-payments. 4. After your insurance company has paid their portion, if there is any amount not covered due to your deductible, non-covered services such as routine care, etc., we will send you a bill for the amount due. We ask that you remit that owed amount upon receipt of the bill. 5. Many insurance plans DO NOT cover ROUTINE or WELLNESS CARE. You need to be aware of your plan s limitations and restrictions. It is not possible for our practice to be aware of all the different benefit plans and restrictions, and we do not have access to the actual policies. In addition, the insurance companies also tell us that verification of benefits does not guarantee payment. 6. There is quite a bit of bureaucracy involved with insurance health plans. There may be certain circumstances where we will ask you to get involved with your insurance carrier by phone to assist us in providing you with the necessary care, or in getting your claim paid. We feel that you, as the policyholder, should have a direct part in this. I have read and understand the above policies, and agree to cooperate and adhere to them. Patient Name (Printed) Date Patient Signature (or Guardian)

5 CONSENT FOR USE AND DISCLOSURE OF INFORMATION I have reviewed the NOTICE OF PRIVACY PRACTICES of NORTH DALLAS EYE ASSOCIATES and have had all questions answered by this office. I also consent to the use or disclosure of my protected health information for the following purposes: TREATMENT It will be necessary to share protected health information with all members of the treatment team for treatment purposes. This can include employees in this office as well as other providers. PAYMENT Necessary information will be shared with appropriate payer sources and their representatives for payment purposes including, but not limited to eligibility, benefit determination, and utilization review. It will also be necessary for your billing personnel including but not limited to employees, case managers, claims representatives, third party billing services or clearinghouses to have access to protected health information to carry out their job functions. HEALTHCARE OPERATIONS Necessary information will be shared for the continuing operations of this office. Some examples include, but are not limited to peer review, accreditation, credentialing processes, and compliance with all federal and state laws. I understand that my treatment may be conditioned upon my consent. This consent is given freely and I understand that I can revoke this consent at any time in writing which will apply to disclosures and uses made subsequent to the revocation date. Patient Name (Printed) Date Patient Signature (or Guardian)

6 Authorization for Use and Disclosure of Protected Health Information I,, hereby authorize North Dallas Eye Associates to use and/or disclose the following Protected Health Information (PHI) to: Relationship: Relationship: Relationship: This PHI is being used or disclosed for the following purposes: I understand that I have the right to revoke this authorization at any time by submitting a written request and that a revocation is not effective prior to the revocation date. Furthermore, I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I also understand that I have the right to refuse to sign this authorization and that my treatment or eligibility for benefits will not be conditioned upon this authorization. The use or disclosure requested in this authorization will result in direct or indirect compensation to North Dallas Eye Associates, from a third party. This authorization will remain in effect until. (Date of expiration) Signature of Patient or Representative Date Printed Name of Patient or Representative

7 Last Name First Name DOB (mm/dd/yyyy) Preferred Pharmacy Location & City Phone # Referring Physician(s) Specialty Phone # MEDICATION PLEASE LIST CURRENT MEDICATION: None See Attached List ALLERGIES PLEASE LIST ANY MEDICATION ALLERGIES: NONE

8 Last Name First Name DOB (mm/dd/yyyy) Medical Problems Please check if applicable ASCVD atherosclerosis Dementia Juvenile rheumatoid arthritis Acid reflux disease (GERD) Depression Kidney stones Alzheimer's disease Diabetes Type I Leukemia Anemia - chronic Diabetes Type II Lupus - systemic Arthritis degenerative (DJD) Dialysis - hemodialysis Migraine Arthritis - rheumatoid Diverticulitis Multiple sclerosis Asthma Eczema Neurofibromatosis Back pain - chronic Emphysema Obesity Bipolar disorder Epilepsy Osteoporosis Bleeding disorder Fibromyalgia Pain - chronic Brain tumor - benign Gallstones Peptic ulcer disease (PUD) Bronchitis - chronic Gout Peripheral artery disease COPD - Chronic lung disease Grave's disease Prostate enlarged (BPH) CVA - stroke HIV / AIDS Psoriasis Cancer - breast Head injury Renal insufficiency - chronic Cancer - colon Headache - chronic Restless legs syndrome Cancer - lung Hearing loss Rosacea Cancer - prostate Heart attack Sarcoidosis Cancer - skin Heart disease Schizophrenia Cirrhosis Hepatitis C Sickle cell disease Collagen vascular disease Hypercholesterolemia Sjogren's disease Congestive heart failure Hypertension Sleep apnea Coronary artery disease Hyperthyroidism Tuberculosis Crohn's disease Hypothyroidism Vertigo DVT deep vein thrombosis Irritable bowel syndrome

9 Review of Systems Please check if applicable Cardiovascular Constitutional Gastrointestinal Genitourinary chest pain fatigue abdominal pain genital discharge irregular heart beat fever constipation genital lesions shortness of breath night sweats heartburn painful urination weakness nausea urgency weight loss vomiting Negative Negative Negative Negative HEENT Hematologic Metabolic Musculoskeletal dizziness bleeding cold intolerance back pain hearing loss bruising excess hunger joint pain hoarseness tender nodes excessive thirst muscle aches ringing in ears frequent urination stiffness sore throat heat intolerance swelling Negative Negative Negative Negative Neurological Psychiatric Respiratory Skin balance problems anxiety cough hair loss headache depression trouble breathing rash numbness insomnia wheezing skin lesions tingling irritability nervousness Negative Negative Negative Negative Social History Please check if applicable Smoking Alcohol Recreation Drugs Occupation Hobbies Frequency Frequency Frequency 1 Current Everyday Smoker Never Never Business Computers 2 Current Some Day Smoker Rarely Rarely Manual labor Music 3 Former Smoker Occasional Occasional Office work Sewing 4 Never Smoked Daily Daily Retired Sports 5 Smoker, Status Unknown Frequently Frequently Student Travel 9 Unknown if Ever Smoked Heavy Heavy Teacher Type of Tobacco Type of Alcohol Type of Drug Cigarettes Beer Amphetamines Cigar Liquor Cocaine Pipe Wine Intravenous drugs LSD Marijuana Other Other Other Other Other

10 Family History Please check if applicable Eye Problems Aunt Brother Cousin Daughter Father Grandfather Grandmother Mother Nephew Niece Sister Son Uncle Other Amblyopia Angle closure glaucoma Astigmatism Cataract Choroid melanoma Corneal dystrophy Corneal graft Diabetic retinopathy Glaucoma High myopia Macular degeneration Retinal detachment Strabismus Medical Problems Aunt Brother Cousin Daughter Father Grandfather Grandmother Mother Nephew Niece Sister Son Uncle Other Anesthetic complications Bleeding disorder Brain tumor Cancer Diabetes Heart disease Hypertension Migraine Neurofibromatosis Rheumatoid arthritis Stroke Systemic Lupus Thyroid disease

11 Past Surgical History Please check if applicable Right Left Date Right Left Date Abdominal aneurysm repair Angioplasty Appendectomy Back surgery Bladder repair Brain aneurysm repair Brain tumor removal Breast implants Breast reduction Breast removal CABG coronary artery surgery Caesarian section Cancer surgery - breast Cancer surgery - colon Cancer surgery - kidney Cancer surgery - lung Cancer surgery - ovarian Cancer surgery - prostate Cancer surgery - skin Cancer surgery - thyroid Cancer surgery - uterus Carotid endarterectomy Carpal tunnel surgery Cholecystectomy Cochlear implant Colon resection Coronary angioplasty Coronary artery stents Ear tubes Face lift Fracture repair - back Fracture repair - facial Fracture repair - hip Gall bladder removal Gastric bypass surgery Hip replacement surgery Hemorrhoid removal Hysterectomy Intestinal surgery Kidney resection Knee replacement surgery Liposuction Liver biopsy Ovary removal Pacemaker Pituitary adenoma surgery Prostate removal Prostate surgery - TURP Rotator cuff surgery Shoulder surgery Shunt - lumboperitoneal Shunt - ventricular Sinus surgery Splenectomy Testicular removal Thymus resection Thyroid resection Tonsillectomy Transplant - heart Transplant - kidney Transplant - liver Transplant - lung TURP- prostate surgery Eye Surgeries History Please check if applicable (Right Eye) Surgery Date (Left Eye) Surgery Date (Right Eye) Surgery Date (Left Eye) Surgery Date Anterior Segment Surgery Cataract & IOL Surgery Cornea Surgery Glaucoma Surgery Globe Surgery Lacrimal Surgery Oculoplastic Surgery Orbital Surgery Refractive Surgery Retinal Surgery Strabismus Surgery Vitreous Surgery

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