METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ (201)

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1 METROPOLITAN EYE CARE Scott B. Pomerantz, M.D., Thomas J, LoPresti, O.D. 523 Forest Avenue Paramus, NJ (201) Please complete and sign where indicated Patient Information: Last Name: First Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Ext: Cell Phone: ( ) - Sex: Male Female Date of Birth: / / Age: Soc. Sec. No.: - - address: Employer: Employer Address: Occupation: Is the Patient a Student? Yes No If YES, Name of School: Is the Patient? Single Married Separated Divorced Widowed If you circled married, please complete spouse Information below: Spouse's Last Name: First Name: Date of Birth: / / Soc. Security No.: - - Is Spouse Currently Working? Yes No Employer: Employer Address: Work Phone: ( ) - Ext.: How did you hear about our practice? (Name of person)

2 METROPOLITAN EYE CARE Scott B. Pomerantz, M.D. Thomas J. LoPresti, O.D. Paramus Professional Building 523 Forest Avenue Paramus, NJ Tel One of the most important parts of your eye exam today is the refraction. This is the part of the exam by which we determine whether you can be helped in any way by a new glasses prescription. It is also how we determine the best possible visual acuity and function of your eye, which is essential medical information for us to have as we assess your eyes and look for problems. It is NOT a covered service by Medicare and many other insurance plans. These plans consider refraction a "vision" service not a "medical" service. Our office fee for refraction is $50.00 and unless your plan automatically covers the refraction charge, this fee is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly. 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 and understand that any co-payment, coinsurance or deductible I may have are separate from and not included in the refraction fee. I decline the refraction service today. I understand that without the refraction, Dr. Pomerantz, Dr. LoPresti or Dr. Sood may not be able to fully assess the health and function of my eyes. If you decline the refraction, we will not be able to prescribe eyeglasses or contact lens prescriptions. Signature: Date: Print Name:

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5 Emergency contact: Give the name of the nearest relative or of a close friend not living with you. Name: Home Phone: ( ) - Relationship: City: State: Who is the Patient's Primary Care Physician? Name: - Address: Phone Number: ( ) "PAYMENT FOR SERVICES" In order to avoid any misunderstands regarding our payment policy, we ask that you please read and sign the following. It is your responsibility to know the provisions of your insurance plan. Please give the receptionist a copy of your INSURANCE card(s), and REFERRAL form if your insurance company requires you to have one for this visit. You will not be seen unless you provide our office with the proper insurance documentation. Payment is due in full at the time of service if you do not have any insurance coverage or if our physicians do not participate with your insurance plan. Please contact and verify that we are innetwork provider with your insurance company, All co-pays and refraction fee are duo at the time of service. If we participate with your insurance plan, we will submit your claim for you provided that you presented your insurance card at the time of visit. However, you will be responsible for any amount that becomes patient responsibility (included but not limited to refraction fee, co-pays, deductibles, co-insurances, and non-covered services under your plan coverage). Please understand that your Insurance card is not a guarantee of payment. You are ultimately responsible to the practice for payment on services regardless of insurance coverage. It is also your responsibility to provide updated and accurate demographic and insurance information at each visit. Failure to do so may result in your claim being denied, making payment your responsibility. Your signature below indicates that you have read, understood and agree to all the above policies. (Patient Signature) (Date)