THE EYE INSTITUTE. Dear Patient:

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1 THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ p f Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ p f Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest level of medical care. Our doctors are ophthalmologists, who are trained in the diagnosis and treatment of diseases of the eye. If possible all evaluation and testing will be completed on your initial visit. Patients should realize that a complete eye exam with or without testing, could last anywhere from one hour to one and a half hours. First time patients must provide a thorough medical history, including all medications. Enclosed is a form to aid in obtaining your medical history. Also enclosed you will find our patient demographic sheet, financial policy and HIPAA Notice of Privacy Practice. Please complete ALL forms and bring them with you to your office visit. At your visit, a vision test and measurement of intraocular pressure will be performed, followed by dilation of the pupils with eye drops. Approximately 20 minutes later, pending adequate dilation of the pupils your physician will complete your examination. Depending on your physician s findings additional testing may be performed. Routine eye exams require a refraction (examination to determine if glasses need to be prescribed or updated) to be performed. Some insurance companies DO NOT cover this, which may require an additional fee of $45. Dilating drops will cause your vision to be blurry (especially up close) for a length of time that varies from person to person and bright lights may be bothersome. It is impossible for the doctor to predict how long you vision will be affected. Sunglasses may be helpful in reducing the glare. You may want to make arrangement for someone to drive you home. If your wear contact lenses and need a renewal on your prescription, you will need to have a contact lens evaluation. This is not covered by insurance companies and will require an additional fee of $ What you need to bring: Photo ID Your insurance cards Referral from your primary care physician, if your insurance requires it. Eyeglasses Contact lenses with packaging or contact lens prescription Past medical records and diagnostic testing from previous eye doctors A list of your current medications A list of your allergies If your visit is for routine eye care examination of eyes, vision, contact lenses, please be aware that not all insurance plans cover these benefits. Please check with your insurance company to see if these benefits are covered under your plan. If you have any further questions, please feel free to contact the office. LK 3/2013

2 Eye Institute Patient Information Sheet Patient Information Date: Primary Insurance Information First Name: MI: Last Name: Date of Birth: Age: SS#: Gender: Address: City: State: Zip: Home #: Work #: Cell# _ Employer: Address: City: State: Zip: DUE TO NEW FEDERAL REGULATIONS, WE NEED TO ASK THE FOLLOWING: Race/Ethnicity: []African American []Asian/Pacific Island []Caucasian []Hispanic []Native American []Other Primary Language Insurance Co Name: ID#: Group#: Policy Holder Name: Policy Holder DOB: Sex: Policy Holder SS#: Relationship to Policy Holder: Policy Holder Address: City State: Zip: Employer Name: Address: City: State: Zip: Telephone #: Does your insurance require a referral? Does your insurance company allow one routine visit per year? Do you have a vision plan? Primary Care Physician Name: Phone: Address: City: State: Zip: Pharmacy Name: Phone: Address City: State: Zip: Emergency Contact Name: Relationship: Phone#: Referred By: Secondary Insurance Information Insurance Co Name: ID#: Group#: Policy Holder Name: Policy Holder DOB: Sex: Policy Holder SS#: Relationship to Policy Holder: Policy Holder Address: City State: Zip: Employer Name: Address: City: State: Zip: Telephone #: LK 3/2013

3 Patient Medical History Name: Age: Date: EYE HISTORY: Have you had: YES NO Diabetic Retinopathy Macular Degeneration Glaucoma Cataract Eye Injury Glasses or Contact Lenses YES NO Contact lens prescription: Brand: RT: Power BC DIA LT: Power BC DIA (please bring your contact lens boxes with you to your appointment) Eye Surgery of Laser (if yes, date/type of surgery/operating surgeon) Right eye: Left eye: Any other problem needing eye medication? If yes, please explain: Present Eye Medication: None Artificial Tears Zinc/Vitamins List others: PAST MEDICAL HISTORY: YES NO Diabetes: Years High blood pressure Asthma Heart Disease Cancer: type YES NO Stroke Thyroid disease Arthritis Other List any other major illnesses or injuries you have had: PAST SURGICAL HISTORY (list type of surgery and approximate date): No prior surgery ALLERGIES TO MEDICATIONS: NONE YES, LIST: PRESENT MEDICATIONS: None PLEASE CONTINUE ON OTHER SIDE

4 FAMILY HISTORY: Have any blood relatives had: YES NO Relationship to patient Cataracts Blindness Glaucoma Macular degeneration Retinal detachment Diabetes Other eye diseases (please list) SOCIAL HISTORY: Current Occupation: Do you use: Tobacco? if yes, how much per day? Alcohol? if yes, how much per day? Street drugs? if yes, how much per day? Do you have or have you had any sexually transmitted disease? HIV/AIDS? REVIEW OF SYSTEMS: YES NO Fever/ chills/weight change Hearing or sinus problem EXPLANATION OF PROBLEM Hoarseness/difficulty swallowing Chest pain/palpitations/heart problems Shortness of breath/cough/lung problems Digestive/intestine problems Kidney/bladder/genital problems Muscle/joint pain; Arthritis Skin rashes/sores Breast lumps/discharge Weakness/numbness/seizures Depression/anxiety/emotional problems Excessive thirst or urination; hormone problems Easy bruising/bleeding/anemia Swollen glands/immune system problems Hay fever/allergies History reviewed No changes Additions as above Physicians signature:, MD Date: LK/04/2011

5 PATIENT NAME: INFORMATION AND CONSENT FOR DILATED EYE EXAMINATION Dear Valued Patient: It may be important to your care today to dilate your eyes. Dilating eye drops are used to enlarge the pupils of the eye to allow the physician to obtain a better view of the inside of your eyes. Dilation frequently changes vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for us to predict to what degree your vision will be affected. Driving may be difficult immediately after the examination. If you are concerned about these problems, you may wish to make alternative transportation arrangements, although a large number of patients do drive after dilation with the assistance of temporary sunglasses, which we can provide after your dilation. Adverse reactions, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I hereby authorize the physician and/or such assistants as may be designated by him to administer dilating eye drops. The eye drops are necessary to perform a complete exam of the retina and the back of the eye. This may reveal the presence of a serious systemic condition as well as eye conditions. You further understand and acknowledge that you have been warned of the potential risks that dilating drops may have on your ability to drive and will take appropriate steps to reduce this risk by not driving immediately after your eyes have been dilated or by wearing sunglasses while driving. I agree to have the dilation examination today. Patient Signature (or person authorized to sign for the patient) / / Date INFORMATION AND CONSENT FOR REFRACTION Thank you for choosing the Eye Institute as your eye care provider. We MAY need to perform a vision test called a refraction (description below) to check your vision today. A refraction is a diagnostic test used to determine the patient s best ability to see. A refraction is the specific measurements of the refractive state of the eye. A series of lenses are presented to determine which prescription provides the sharpest and clearest vision. This is an essential part of most ophthalmologic evaluations. This test is performed during your annual eye exam or if there has been a decrease in your vision since your last visit. This test is necessary to perform in order for your physician to determine the best visual acuity which is needed to evaluate for possible eye diseases. Occasionally the refraction is used as the basis for prescribing glasses or other optical devices. However often a refraction does not lead to prescription for glasses. MOST INSURANCE COMPANIES INCLUDING MEDICARE DO NOT COVER THE REFRACTION TEST. Our office fee for a refraction is $45. This fee of $45 is collected in addition to any co-payments, coinsurance or deductible payments at the time of service. I accept full responsibility for the cost of this service. / / Patient Signature (or person authorized to sign for the patient) Date INFORMATION AND CONSENT FOR CONTACT LENS EVALUATION In order to update or change your prescription for contact lenses, we will need to perform a contact lens evaluation. This evaluation involves checking vision with current lenses, and presenting a series of alternate lenses to determine which prescription provides the sharpest and clearest vision. It also involves an evaluation of the fit and centration of the lenses by the physician using the microscope. This testing is needed to insure that the lenses are not adversely affecting your eyes. Our office fee for a contact lens evaluation is $35. This fee is collected in addition to any co-payments, coinsurance or deductible payments at the time of service. I accept full responsibility for the cost of this service. / / Patient Signature (or person authorized to sign for the patient) Date BK 3/2013

6 EYE INSTITUTE FINANCIAL POLICY We are dedicated to providing you with the best possible care. If you have medical insurance, we are committed to helping you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policy. Ultimately any and all financial liability rests with the patient. If you have no insurance or are a member of insurance plans that we don't participate in FULL PAYMENT FOR SERVICES IS DUE AT THE TIME THEY ARE RENDERED. We accept cash, personal checks, and credit cards. HMO and Managed Care Plans: Co-payment is due at the time of check-in. If a referral is required from your primary care physician, you are responsible for obtaining it prior to your appointments; in the absence of a referral, you will be responsible for the full charges at the time of your visit. Medicare: You are responsible for your annual deductible and 20% co-insurance payment at the time of service. In addition, you are generally responsible for durable equipment and non-covered services. Please note that refraction is a noncovered service according to Medicare regulations. For any questions about the non-covered refraction, please call Medicare. Workers' Compensation: You are responsible for promptly submitting our bill to your employer. You will be responsible for any bills not paid within thirty (30) days. Motor Vehicle Accidents: We are not responsible for submitting bills to your insurance company. You are responsible for any deductibles or co-payments, and will be fully responsible for any bills not paid within thirty days (30) days. Hospitalization: Our physician fees for hospital visits, including surgery, will be billed directly to your insurance company. You are responsible for any non-covered fees. Our fees do not include charges for the hospital or hospital dispensed medications, or another physician's fees. Responsible Parent: In case of divorced or separated parents, our policy is that the parent bringing the child into our office is responsible for the full payment of fees. Contact Lenses: Payment or credit card information is required at the time an order is placed. Returned Checks: Any check payments that do not clear the bank will be subject to a $45.00 returned check fee. Cancellation Policy: We require 24 hours notice of appointment cancellation. If the appointment is not cancelled earlier than 24 hours prior to its scheduled time, we reserve the right to charge a $75.00 fee. If the patient misses three (3) appointments, the physician can, at his discretion, send your records to the physician of your choice. We will gladly discuss your proposed treatment and answer any questions related to our fees. We will also be happy to discuss general questions concerning insurance; however, please understand that we cannot be familiar with the specific terms of every insurance issued. That is between you and the insurance company with whom you have contracted. Therefore, for specific answers to questions, you may need to call your insurance company directly. I request that payment of authorized Medicare and/or insurance benefits be made on my behalf to my provider at Eye Associates of Wayne for any services furnished by them. I authorize any holder of medical information about me to release to Healthcare Financing Administration, its agents, or any other carrier I may have, any information needed to determine these benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. I understand and agree that, regardless of my insurance status, I am ultimately responsible for all charges for professional services rendered to me, or my dependents. In the event that my account becomes delinquent for more than sixty (60) days, I also agree to pay a collection fee of $10 plus 5% of the balance due, as well as 1.67% monthly interest and any attorney fees associated with the collection of this account until the balance has been satisfied. I have read and understand the information in this financial policy, and assignment of benefits Signature Date Parent's Signature (if minor) Date Acknowledgement of Receipt of Privacy Notice I have been presented with a copy of the Eye Institute Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information: I also acknowledge receipt of this Notice of Privacy Policies on behalf of the minors listed below. Name (printed) D.O.B. Signature If not signed by patient, please indicate relationship to patient. Relationship: Date Please list minor children covered by this acknowledgment: Name: Name: Name: DOB DOB DOB BK 3/2013

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