WELCOME TO OUR PRACTICE! Giving all patients who enter the practice a healing and loving touch

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1 WELCOME TO OUR PRACTICE! Thank you for choosing our office to serve your eye care needs. Since 1999 Visionary Ophthalmology is dedicated to providing the highest level of care to its patients and community by combining three essential elements of patient care: Using state-of-the-art technology Providing care in a highly efficient and timely manner Giving all patients who enter the practice a healing and loving touch We are a full-service General Ophthalmology practice that specializes in: Complete Eye examinations for adults and children Routine Eye Exams Diagnosis of eye disease such as glaucoma, cataracts, diabetic retinopathy & macular degeneration Treatments for dry, irritated or tearing eyes, including punctal plugs & nutraceuticals LASIK Refractive Surgery Cataract Surgery Pre- and Post-Operative care Contact lens fittings, even for hard-to-fit patients The day of you exam, we will dilate your eyes so the doctor can check their overall health. The doctor may request additional tests if necessary. To make your visit go as smoothly as possible, please complete the enclosed registration forms and bring them with you the day of your appointment. Be sure to sign and date where required. Also, please bring: your insurance card (including any vision plans), photo ID, and a Primary Care Physician Referral (if your insurance requires one, HMO and POS). Please allow at least 2 hours for your exam. (Part of this time is spent waiting for your eyes to dilate). Additional testing may require more time. Contact lens fittings also take additional time. To better serve you, we have an Optical on-site with competitive pricing, selection and styles. We accept almost all Vision plans. We also have a Skin Care center on-site, Lumina Skin Center, dedicated solely to skin care aesthetic procedures, using the latest technologies, treatments and products. We look forward to meeting you. Please feel free to call us if you have any additional questions prior to your visit. Sincerely, Visionary Ophthalmology Doctors and Staff

2 REGISTRATION FORM Please complete all the information indicated below Date: Patient Name: Date of Birth Age Last name First name MI Gender M F Marital Status Single Married Other Social Security # Address: Apt# City/State/Zip: Home #: Cell #: Work#: Please Indicate Preferred Contact Number: Address: Employer: Occupation: Emergency Contact: Relationship: Phone #: Primary Care Physician: Primary Care Physician Phone#: Last Name First Name Doctor that referred you to our office: Referring Doctor Phone #: (if applicable) Last Name First Name How Did You Hear About Us Friend/Family: Doctor/Primary Care Doctor: Radio: Internet: TV or print? Other: -Billing and Insurance Information- Primary Insurance: ID#: Group #: Policy Holder s Name: Date of Birth: SS#: Relationship to Patient: Secondary Insurance: ID#: Group #: Policy Holder s Name: Date of Birth: SS#: Relationship to Patient: -Information of responsible party - For minors- Parent #1: Parent #2: Date of Birth: SS#: Date of Birth: SS#: Address Address : Home #: Work #: Home #: Work #: Employer: Employer: ARE YOU COVERED BY ANY VISION PLAN? VSP DAVIS VISION SPECTERA OTHER * If you would like to use your vision plan benefits, we must have a proper ID number the day of your visit* RECEPTIONIST INITIALS:

3 OUR FINANCIAL POLICY AND OTHER IMPORTANT INFORMATION FOR THE DAY OF YOUR APPOINTMENT: PLEASE READ At Visionary Ophthalmology, we strive to provide you with the highest level of service and the best medical care. In return, it is your responsibility to provide us with your insurance information. Please bring the following to your eye exam: all current insurance cards (medical and vision insurance), referral information (if required by your insurance), eyeglasses, sunglasses, contact lenses and contact lens prescription information, eye medications, and a complete list of ALL medications. If you wear contacts, wear them to the eye examination. MEDICAL INSURANCE AND VISION PLANS: If you have a routine vision plan you must inform the receptionist at the time of check in. Our office participates with most medical insurance plans and routine vision plans. Medical insurance plans will cover medical eye problems, such as dry eye, eye allergies, cataracts or glaucoma, but usually they do not cover the cost of glasses, contact lenses, and routine vision care, such as refraction (below). Routine vision plans will cover only routine eye exams, but will not cover a medical eye problem. During your routine exam, if you are diagnosed with a medical eye problem, we will submit a claim to your medical plan. All vision plans are different, and some of them cover part of the refraction. As a courtesy to you we will try to verify benefits prior to your visit. PLEASE NOTE: If your appointment is set as a routine eye exam but at some point your exam becomes medical because a medical diagnosis is found, and you need a prescription for glasses the same day, we will bill both: your medical insurance and your vision plan for your refraction. PATIENT INITIALS GLASSES PRESCRIPTION: One of the most important parts of your eye exam is the Refraction. A Refraction test determines not only your most accurate eyeglass prescription, but also the best possible vision and function of your eye and it helps our Doctors make a better decision about your treatment options. The Refraction is not considered a "medical service" but a "vision service and Medicare and most insurance carriers do not cover it. Our office fee for Refraction is $67.00 and it should be paid at the time of service. We will be happy to bill your insurance company and; should they cover and pay for it, we will reimburse you accordingly. If you have a vision plan, we will also bill your Vision Plan for the refraction. HMO PLANS/REFERRALS: Our office participates with most insurance plans, including Visionary Ophthalmology Financial Policy and the day of your appointment important info PATIENT INITIALS

4 HMO s. Managed care plans require us to have a valid authorization or referral at the time of service. It is our policy that patients are responsible for obtaining necessary referrals for any office visits or procedures from their primary care physician. Referrals must be in hand at the time of the exam or procedure. We accept faxed referrals from the primary physician s office prior to the appointment, but will not accept any referral after the exam or procedure date. If you do not have a referral at the time of your visit your appointment can be rescheduled until you obtain a referral. The referral is your responsibility. If you choose to be seen without a referral or fail to inform us of any changes to your health insurance coverage, group number, or ID number, you are responsible for any charges due in full at the time of service. CONTACT LENSES: In most cases medical insurance and routine vision plans do not cover the cost of a contact lens evaluation, prescription verification, or fitting. The charge for these contact lens services is a separate and additional charge to the eye exam. The charge for these services varies from $50 to $300, depending on the complexity of the contact lens prescription, the type of contact lens being fit, and the need for instruction on contact lens insertion and removal. Please inform our staff when you make the appointment and at the time of check in if you would like to be fit with contact lenses, or if you would like your contact lens prescription updated or verified. PATIENT INITIALS SURGERY: CANCELLATION FEE: There is a $ administrative fee if you wish to cancel or change the date of surgery and notice is not provided at least 3 days prior to surgery. Post-Surgical Kit: Insurance companies do not cover the cost of post-surgical kits ($2O.OO), therefore it will be the patient's responsibility to assume such payment SELF PAY /NO INSURANCE: If you are the sole party responsible for all charges incurred, we ask that you make your payments at the time of service. If your treatment is extensive, or you require any type of surgical procedure including any refractive procedures, we offer 0% financing for up to 12 months with Care Credit and Chase Health Advance to help make your payments more manageable. NO SHOW FEE: We request that you keep scheduled appointments and arrive on time. Cancellations of less than 24 hours prior to your appointment, or No- Show for your appointment will result in a $35 MVA AND OTHER FORMS: If you need any special forms completed (i.e. Motor Vehicle Vision, Military Vision, etc...) these services can be provided for a nominal charge. Visionary Ophthalmology Financial Policy and the day of your appointment important info PATIENT INITIALS

5 THE DAY OF YOUR APPOINTMENT EYE GLASS/CONTACT LENS PRESCRIPTION: If you wish to get an updated eyeglass OR contact lens prescription, or if you feel there may be a change in your vision please inform us at the beginning of the exam. Once eye drops are placed in your eyes, it is too late to perform refraction or contact lens evaluation as your vision will be blurred by the drops. In general, unless the tested vision is not good or you are having visual problems, refraction may not be necessary. CONTACT LENSES PRESCRIPTION: It is important but not essential for you to know what contact lens prescription you are wearing (manufacturer, brand name, power, base curve, and diameter). If you have the contact lens vial or packaging, bring this with you to the exam. This will expedite the examination process. If you are unable to obtain this information before the eye exam, a complete contact refitting needs to be performed. We recommend that you wear your contact lenses to the eye exam. Please inform the receptionist that you are wearing contact lenses when you check into our office. DILATION THE DAY OF YOUR EXAM: Dilation, for the purpose of examining the back of the eye (retina, optic nerves, blood vessels,), is usually performed as part of the full eye examination with a few exceptions. Some patients do not require dilation every year. Special situations will dictate how frequently your eyes need a dilation exam. Dilation is performed towards the end of the eye exam because dilation will cause the vision to be blurry. Once dilation drops are instilled, it is not possible to perform a refraction or contact lens fitting. Therefore, it is important for you to inform us if you wish to have these tests performed before you are dilated. Dilation is performed with special eye drops which sting momentarily. It usually takes minutes to achieve adequate pupillary dilation, and it usually causes significant light sensitivity and blurred vision for 2 to 4 hours. The duration and severity of these side effects vary from person to person. Bring your darkest sunglasses with you. PLEASE INITIAL ALL PAGES AND SIGN BELOW TO INDICATE YOU HAVE READ THIS FORM Signature of patient/patient Guardian DATE Visionary Ophthalmology Financial Policy and the day of your appointment important info PATIENT INITIALS

6 PRIVACY ACT NOTICE FOR PATIENT Use and Disclosure of Protected Health Information Our "Notice of Privacy Practices" policy, available at the front desk at Visionary Ophthalmology and also online at our website, provides detailed information about how we may use and disclose protected health information about you. The details of this policy are in full compliance with all provisions, including those most recently updated. Acknowledgement & Consent Form for Use and Disclosure of Information Copies of our "Notice of Privacy Practices" provides information about how we may use and disclose protected health information about you, and is compliant with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our Notice of Privacy Practices states that we reserve the right to change terms described. Should this happen, we will display the new policy and effective date in our office. You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. We are not required to agree with your restrictions; but if we do, we are bound by our agreement with you. By signing below, I acknowledge receipt of Notice of Privacy Practices and consent Visionary Ophthalmology use and disclosure of protected health information about me for treatment, payment, and health care operations. I have the right to revoke this consent, in writing, except where the practice has already made disclosures in trust on my prior consent. If you have any questions please call us at Signature: Date: Printed Name: Personal Representative, Family or Other Entities Authorized Access to Protected Health Information to be Used and/or Disclosed Name or specifically identify these persons and/or other entities you are authorizing to make use of and/or to disclose your protected health information regarding treatment, payment and other healthcare operations. Name of Authorized Person or Entity Relationship Phone number Name of Authorized Person or Entity Relationship Phone number Authorization for use of Patient Contact Methods We might be unable to contact patients directly during normal business hours. On these occasions our office contacts patients and leaves messages through the communication devices provided by our patients. Due to the new federally mandated HIPAA Privacy Rule, we must obtain your authorization to continue this mode of communication. Protected Healthcare Information that we may possibly disclose on your home, work, cell phone, or account includes, but is not limited to: test/lab results, prescription/pharmacy information, appointment instructions for visits and procedures, and surgical posting/scheduling information. Yes, I agree to allow Visionary Ophthalmology to leave messages that includes Protected Healthcare information on any of these communication devices: home phone, work phone, cel l phone, and/or account. No, I do not agree to allow Visionary Ophthalmology to leave messages that includes Protected Healthcare information on any of these communication devices: home phone, work phone, cell phone, and/or Macpro Caro/VOServer/Pat.Forms Privacy Act Notice bilingual 09/01/12

7 Signature on File, Assignment of Benefits, Financial Agreement 1) MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Visionary Ophthalmology, for services furnished to me by Visionary Ophthalmology. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made to Visionary Ophthalmology and authorizes the release of medical information necessary to pay the claim. Visionary Ophthalmology accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, co-insurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. 2) MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Visionary Ophthalmology, if possible, or otherwise to me. 3) OTHER INSURANCE: I understand that Visionary Ophthalmology participates in several medical insurance plans. It is my responsibility to determine physician participation in my plan, coverage, applicable co-pays and any other requirements of my policy. I understand my signature requests that payment be made to Visionary Ophthalmology and authorizes release of medical information necessary to pay the claim. I am responsible for the deductible, coinsurance, co-pay, and non-covered services. 4) MINOR PATIENTS: I understand that as the parent/guardian accompanying the patient, I will be fully responsible for payment of services rendered. 5) FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Visionary Ophthalmology, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Visionary Ophthalmology. I understand Visionary Ophthalmology s contracts with health care service plans relate only to items and services which are "covered" by the health care service plans. The undersigned accepts full financial responsibility for any non-covered services, co-pays, deductibles, co-insurance or unauthorized services. If my account is sent to a collection agency, I agree to pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action. It is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill. Patient Name Date Signature of Patient or Authorized party Printed name (if not patient) Macpro Caro/VOServer/Pat.Forms Signature on File, Assignment of Benefits, Financial Agreement 11/01/13

8 DIRECTIONS TO OUR OFFICE One Central Plaza Rockville Pike, Suite 1202 Rockville, Maryland *We are conveniently located directly across from the White Flint Mall* PLEASE NOTE ENTRANCE TO THE BUILDING IS ON SECURITY LANE NOT ON ROCKVILLE PIKE FROM GAITHERSBURGIGERMANTOWN: Merge onto I-270 South. Keep RIGHT to take I-270 LOCAL S via EXIT 8 toward SHADY GROVE RD/LOCAL LANES. Take EXIT 4A MONTROSE RD EAST. Merge onto MONTROSE RD. Merge RIGHT onto MONTROSE PARKWAY. Turn RIGHT onto EAST JEFFERSON STREET. Turn LEFT onto OLD GEORGETWON ROAD. TURN RIGHT onto ROCKVILLE PIKE. After passing through the intersection for NICHOLSON LANE, take a right at the next light which is SECURITY LANE. One Central Plaza is the big brown building on the LEFT. -FROM SILVER SPRING: Merge onto I-495 W/CAPITAL BELTWAY/I-495 OUTERLOOP toward N VIRGINIA. Merge onto ROCKVILLE PIKE/ MD-355 N via EXIT 34 toward WISCONSIN AVE/BETHESDA/ROCKVILLE. Turn LEFT on SECURITY LN. One Central Plaza is the big brown building on the LEFT. -FROM NORTHERN VIRGINIA: From the Beltway (I-495 W) takes I-270 North towards Frederick. Take the DEMOCRACY BLVD exit, EXIT 1.Take the ramp toward MD-187/OLD GEORGETOWN RD. Merge onto DEMOCRACY BLVD. Turn LEFT onto MD-187 N/OLD GEORGETOWN RD. Turn SLIGHT RIGHT onto ROCKVILLE PIKE/MD-355 S. After passing through the intersection for NICHOLSON LANE, take a right at the next light which is SECURITY LANE. One Central Plaza is the big brown building on the LEFT. Metro Rail (RED LINE towards Shady Grove) Walking Directions: When exiting the White Flint Metro Station, Rockville Pike will be on your right and Marinelli Road will be directly in front of you. Continue South on Rockville Pike (straight ahead) for 1.5 blocks. Once you pass Nicholson Lane, our office will be located half block to your right side across the street on the corner of Rockville Pike and Security Lane. (You need to cross the street). PLEASE NOTE ENTRANCE TO THE BUILDING IN ON SECURITY LANE, NOT ON ROCKVILLE PIKE; WE ARE LOOKING FORWARD TO SEEING YOU! Macpro Caro/VOServer/DIRECTIONS/ENG. 09/01/12