PLEASE REMEMBER THAT REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR YOUR BILL.

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1 Welcome to Our Office! We welcome you to our office and appreciate the opportunity to provide you with medical services. We strive to provide the highest quality eye care to our patients with compassion and integrity. Fees and Payments: We make every effort to keep down the cost of your medical care. It is our policy to ask for payment at the time of your visit. For your convenience, we accept Visa, Mastercard, American Express and Discover. As a convenience to all our patients, we also offer easy-pay. It s a program where we simply maintain your credit, debit or check card information on file to capture any co-pay, deductibles or balances not covered by insurance. Insurance: Your insurance contract is an agreement between you and your insurance carrier. We participate with most major insurance carriers including Blue Cross and Blue Shield and most HMO s and PPO s. As required by most insurance carriers, you are responsible for the payment of deductibles, co-payments and any non-covered services at the time of your office visits. It is your responsibility to get an authorization or referral from your insurance company or primary care physician if that is required or you will be charged the full amount on the day of the visit. HMO/POS Insurance: PPO Insurance: Medicare Insurance: Private Insurance: No Insurance/Self Pay: Current Insurance: You must have a current HMO card and a referral sheet from your Primary Care Physician and pay your applicable co-pay or deductible. If you do not have any referral, your visit may be rescheduled or you may be financially responsible for the entire amount. Your applicable co-pay or deductible is due at the time of service. You must have a current PPO card. Your applicable co-pay or deductible is due at the time of service. You must have a current Medicare card, and be prepared to pay your deductible and/or 20% of the allowed charges, if you do not carry a secondary medical insurance. We expect you to pay your deductible and/or 20% at the time the services are rendered. We will file a claim with your insurance carrier. We ask for payment in full at the time of service. If the insurance information you give us at the time of your visit is not correct, you will be held responsible for payment. If you have any insurance questions, please call the insurance department at PLEASE REMEMBER THAT REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR YOUR BILL. Patient Signature

2 Refraction Notice: An important part of your eye exam today is the refraction which determines if 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 rule out problems. Medicare and most insurance companies DO NOT cover the charge for a refraction. Our office policy is to charge $25.00 for this procedure in addition to the office visit co-pay and/or deductible. Payment is due at the time services are rendered. Please inform the technician if you decline a refraction today. It is important to understand that if you decline, we may not be able to determine the cause for your decrease in vision. 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. Patient Signature Medicare Notice: Medicare Allowable Benefits: (at 80% after deductible is met) Medically diagnosed office visits Surgery Test and procedures Spectacle lenses after cataract and IOL surgery Frames up to Medicare s allowable Contact lenses after cataract surgery Medicare Non-allowable Benefits: (patient responsibility) Yearly deductible 20% not paid by Medicare Glasses (except 1 st pair after cataract surgery) REFRACTION Yearly contact lens check by technician Limited field exams for driver s license Routine eye exams for glasses Multifocal IOL s I have been informed of the Medicare allowable and non-allowable benefits. I understand and agree to pay for yearly deductibles, 20% co-pay, and non-allowable benefits. I understand that any additions to above covered glasses will be at my expense. I hereby authorize Medicare to make direct payment to the undersigned physician for my medical/surgical benefits Patient Signature

3 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPPA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly Obtain payment from third-party payers Conduct normal healthcare operations such as quality assessments and physician certifications I understand that the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information are available to read upon request. I also understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name Signature Relationship to Patient

4 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION TO A DESIGNATED INDIVIDUAL This Authorization grants permission to Designated Party/Parties named below to: make or confirm appointments; have access to X-ray, laboratory or test findings; have access to telephone communications and answering machine messages as well as other common means of communication; pick up sample medications and prescriptions; pick up correspondence; be made aware of my diagnosis, prognosis and treatment plans; have access to my financial health information; and accompany me to exam rooms during routine exams. I hereby authorize Carolina Vision Center to use and disclose my protected health information as described above. I understand that this authorization is voluntary. I understand that once the information is disclosed to the Designated Party/Parties named below, the released information may no longer be protected by federal privacy laws, statues, acts or regulations. Patient Name Designated Party Address Designated Party Address SSN Relationship to Patient Phone Relationship to Patient Phone The patient or the patient s representative must read and initial the following statements: I understand that this Authorization will (must select one by initialing) Expire 1 year from date signed by patient or patient s representative Be effective for the lifetime of the patient unless revoked (see #2 below) I understand that I may revoke this Authorization at any time by notifying Carolina Vision Center in writing, however if I do revoke the Authorization, it will not affect any actions taken by Carolina Vision Center prior to the receipt of the revocation. I understand that my treatment cannot be conditioned on whether I sign this Authorization Signature of patient or patient s representative Printed name of patient or patient s representative ***YOU MAY REFUSE TO SIGN THIS AUTHORIZATION***

5 The final HIPPA privacy rules prohibit the notice and consent from being combined into a single document. Carolina Vision Center Patient Consent Form Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting Carolina Vision Center at (910) or at 2047 Valleygate Drive Fayetteville, NC You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operation. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. Patient Signature

6 Patient Name Please list all Medications you are currently taking at this time. Medication Dose MGs Medication Dose MGs Please list any Medications you are allergic to. Medication Dose MGs Medication Dose MGs

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