Patient Information (please print cleary)

Patient Information (please print cleary) Patient Name Male Date of Birth (mm/dd/yy) Social Security Number Female Address City State Zip Code Home Phone Number Cell Phone Number Email Address Employer Employer Phone Number Employer Address City State Zip Code Guardian/Responsible Party Date of Birth Relationship Social Security Number Address (if different) City State Zip Code Name of Primary Insurance Company Name of Secondary Insurance Company Identification Number Identification Number Group Number Subscriber Name Group Number Subscriber Name Subscriber s Employer Relationship to Patient Referring Physician Address Phone Number Primary Physician Address Phone Number

Medical History Patient Name: _ Date of Birth: HAVE YOU EVER HAD THE FOLLOWING: 1. Hospitalization for illness or injury 2. Heart problems 3. Heart murmur 4. Rheumatic fever 5. Scarlet fever 6. High blood pressure 7. Low blood pressure 8. Stroke 9. Artificial prosthesis (heart valve or joint) 10. Anemia 11. Prolonged bleeding 12. Emphysema 13. Tuberculosis 14. Asthma 15. Sinus problems 16. Kidney disease 17. Liver disease 18. Jaundice 19. Thyroid or parathyroid disease 20. Hormone deficiency 21. High cholesterol 22. Diabetes 23. Stomach ulcer 24. Digestive disorders 25. Arthritis 26. Glaucoma 27. Contact lenses 28. Head or neck injuries Y N Y N 29. Epilepsy, convulsions (seizures) 30. Viral infections and cold sores 31. Any lumps or swelling in the mouth 32. Hives, skin rash, hay fever 33. Venereal disease 34. Hepatitis (type) 35. HIV/AIDS 36. Tumor, abnormal growth 37. Radiation therapy 38. Chemotherapy 39. Emotional problems 40. Psychiatric treatment 41. Antidepressant medication 42. Alcohol/Drug dependency ARE YOU CURRENTLY: 43. Being treated for an illness 44. Aware of a change in general health 45. Often exhausted or fatigued 46. Subject to frequent headaches 47. A heavy smoker 48. Experiencing eye pain 49. Having blurred vision 50. Having double vision 51. Experiencing loss of vision 52. Having facial pain

Medical History (continued) VISUAL FUNCTION: (check all that apply) Do you have difficulty, even with glasses, with the following activities? Reading small print? Reading a newspaper? Reading books? Recognizing people when they are close to you? Seeing steps, stairs or curbs? Reading traffic, street or store signs? Writing checks or filling out forms? Cooking? Watching TV? Playing board games, cards or Bingo? Playing sports (golf, tennis, bowling)? Have you been bothered by? Bright lights? Poor night vision? Seeing rings or halos around light? Double vision? Seeing in dim light? Poor color vision? Driving (check all that apply) Do you currently drive a car? Do you have problems driving during the day because of your vision? Do you have problems driving at night because of your vision? Y N FAMILY MEDICAL PROBLEMS: (check all that apply) 1. Diabetes 2. High blood pressure 3. Heart disease 4. Stroke 5. COPD/Emphysema 6. High cholesterol 7. Anesthesia Problems 8. Arthritis 9. Eye Diseases Y N Other Medical Problems? Previous Surgery? Current Medications? Drug Allergies? IF EYE SURGERY COULD IMPROVE YOUR VISION, DO YOU FEEL YOUR VISION IS CURRENTLY BAD ENOUGH TO CONSIDER SURGERY AT THIS TIME? _YES _NO Patient Signature: Date: / /

Appointment and Cancellation Policy Effective July 1, 2010 Our goal is to provide quality medical care in a timely manner. In order to do so we have to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care. Scheduled Appointments For a scheduled appointment please call (716)881-7900 Cancellation of an Appointment In order to be respectful of the medical needs of our patients, please be courteous and call the office promptly if you are unable to attend an appointment. This time can then be reallocated to someone who is in urgent need of treatment. This is how we can best serve the needs of our patients. If it is necessary to cancel your scheduled appointment, we require that you call by 12:00 pm one working day in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care. To cancel appointments please call (716)881-7900. If you do not reach the receptionist you may leave a detailed message on the voicemail. Late Cancellations Late cancellations are considered as a no show. No-Show Policy A no show is someone who misses an appointment without cancelling it by 12:00 pm one working day in advance. Noshows inconvenience those individuals who need access to medical care in a timely manner. A failure to present at the time of his/her scheduled appointment we be recorded in the patient s chart as a no show. Three no shows will result in suspension of services. We urge you to make every effort to keep future appointments.

Patient Financial Policy Effective July 1, 2010 Ross Eye Institute is dedicated to providing the best possible care for you. We offer the following to help you understand our financial policy and aid you in planning for payment. Insurance Verification and Co-payment The patient is expected to present an insurance card and a form of picture ID at each visit. If no card is presented at the time of service the patient will be responsible for services rendered. All co-payments and past due balances are due and payable at the time of service. All payments are expected to be made in U.S. dollars. The Ross Eye Institute accepts cash, personal check, VISA & MasterCard. There is a service charge of $30.00 for returned checks. Patients with an outstanding balance of 120 days may be discharged from our practice unless a payment arrangement is made. Unpaid accounts, including payment arrangements not made, will be turned over to a collection agency. Insurance Plan Participation It is the patient s responsibility to be aware of their insurance coverage, policy provisions and authorization requirements. Not all providers participate with all insurances; please verify whether the physician accepts your insurance coverage when scheduling an appointment. We bill non-participating insurance companies as a courtesy to you. Any outstanding balances are the responsibility of the patient. Self-Pay Accounts Self-pay accounts shall exist if a patient has no insurance coverage. A deposit is expected at the time of service, unless prior arrangements have been made with the physician s office. The deposit amounts are as follows: Office Visit = $50 Testing = $25 Surgery = $500 Health Savings Accounts/High Deductibles If your insurance is a Health Savings Account (High Deductible Plan) you will be required to pay a deposit prior to services being rendered. The deposit will be applied to your total cost and you will be billed for the balance owed or issued a refund for an overpayment. No-Fault/Workers Compensation Patients are responsible for providing our office with all information required to properly submit charges, i.e. insurer, claim #, date of injury, etc. Without this information, the fees mandated by New York State will be charged to reflect our private fees and you will be responsible for payment. If you have private insurance with which we participate and obtain any referrals/authorizations, we will submit on your behalf and bill you for any unpaid balance. Medicare We are participating physicians. This means that we must accept Medicare s allowed charge for services rendered. Medicare will pay 80% of the approved amount. The patient is responsible for the remaining 20% plus any out of pocket deductible. If you have secondary insurance, we will submit the claim for the remaining balance after Medicare has paid. Please remember that the patient, by federal law, must be held responsible for any portion of the approved amount not paid by Medicare or a secondary insurance company. Referrals It is the patient s responsibility to know if a referral is required by the patient s insurance carrier. If a referral is required, the patient is responsible for obtaining the referral prior to the time of the visit. If the referral is not obtained, the patient s appointment will be rescheduled.

Patient Policies Effective July 1, 2010 I hereby agree that I have received the Ross Eye Institute Policies. Please initial next to each of the policies that you have received from the office today. _ Appointment & Cancellation Policy _ Financial Policy Patient Name Date Patient or Parent/Guardian Signature

Consent for Treatment and Payment Agreement Authorization for treatment: I authorize Ross Eye Institute, its physician members, and its allied health professionals to provide and administer medications, administer diagnostic procedures, medical/surgical treatment and perform such other diagnostic or therapeutic procedures as such physicians consider necessary for the emergency, outpatient and follow-up treatment for my condition. No physician or allied health professional or employee has assured me that such treatment or procedure will be successful. It is acknowledged that the practice of medicine and surgery is not an exact science and that no guarantees have been made or implied as to the results of treatment or at examination performed at the facility. I understand that it is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he/she has had an opportunity to discuss them with a physician or other allied health professional to his/her satisfaction. I understand that each patient has the right to consent, or refuse consent, to any purposed course of treatment. Any tissues surgically removed may be examined and retained for medical, scientific, or educational purposes, or may be disposed of in accordance with customary practice. I understand that Ross Eye Institute is a designated teaching center by the University at Buffalo. As a teaching site, Ross Eye Institute has a mission to educate and train medical personnel. I understand that staff and my Attending physician will supervise all student involvement in my care. Authorization to release information: I consent the REI, its physician members, and its associated allied healthcare providers and employees may use and disclose protected healthcare information contained in my record to my personal physician, any health insurance carrier, workers compensation carrier, or private or governmental third party liable for payment for the services provided to me, including an employer or self-funded health plan. I consent that Ross Eye Institute, its physician members, other healthcare providers, and employees may provide information contained in my record to the physician or healthcare provider that I have designated as my personal physician or healthcare provider and to any other facility that I have agreed will provide subsequent medical care. I further consent to the use and disclosures of my health information for training and educational purposes to students, Resident physicians, and Attending physicians from the University at Buffalo. Assignment of insurance benefits/medicare/medicaid: I authorize Ross Eye Institute to bill my insurance carrier or others who are financially liable for my care and direct those payments for my care to REI. I also give REI and its employees the right to intervene in any lawsuit or other action brought by me, or on my behalf, to collect amounts due to REI for services rendered to me. I assign all right to benefits, insurance proceeds, settlement payments, or judgments to which I may be entitled to for services provided by REI for physician, professional and technical services related to diagnostic tests and/or procedures and treatments to REI or to the physician or organization furnishing the services; and authorize REI or such physician or organization to submit a claim to the insurance carrier for payment on my behalf. I agree that any amounts not paid by insurance are my own responsibility. Any person who knowingly and with intent to defraud any insurance company or person files a statement of claim containing any materially false information, shall be subject to civil penalty not to exceed $5,000 and the value of the claim for each violation. Financial agreement: In consideration for the services rendered or to be rendered to me (the patient), I agree to be individually responsible to pay my account in accordance with the rates and terms of REI. Should the account be referred to a collection agency or attorney for collection, I shall pay reasonable attorneys fees, costs and collection expenses. All delinquent accounts bare interest at 1.5% per month. Signed: Date: _ Witness: _ Patient or authorized representative Relationship to patient:

Authorization of Release of Information to Family and/or Friends Name of Patient: Date of Birth: I authorize the Ross Eye Institute to release protected health information to the entities below: Give information to spouse/partner: YES NO N/A Name of spouse/partner: _ Give information to a family member or friend (please list): Primary contact number: Contact me at work: YES NO N/A Leave message at work: YES NO N/A Leave message at home: YES NO N/A Description of information to be released to family or friend: Financial/Billing: YES NO N/A Medical Information: YES NO N/A Please list any restrictions regarding information to be released: Rights of the patient: I understand that I have the right to revoke this authorization at any time, and I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to Ross Eye Institute. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective immediately upon receipt of notification by Ross Eye Institute. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal and state law. I understand that I have the right to refuse to sign the authorization and that my treatment will not be conditional on signing this authorization. This authorization shall be in force and effect until revoked by the patient or representative signing the authorization. Signature of Patient or Personal Representative Description of Personal Representative s Authority

Acknowledgement of Receipt of Notice of Privacy Practices By signing below, I acknowledge that I have been offered a copy of UNIVERSITY OPHTHALMOLOGY SERVICES, INC. s Notice of Privacy Practices. Signature _/ / Date Patient Name or Personal Representative Description of Personal Representative s Authority For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify)

Medical History REVIEW OF SYSTEMS: (please circle all that apply) Constitutional fever lethargy weight loss fatigue Nervous System headache seizures poor coordination dizziness Skin rash birth marks easy bruising jaundice Endocrine diabetes thyroid disorder poor weight gain Kidneys/GU incontinence blood in urine genital lesions Ears/Nose/Throat runny nose ear infection decreased hearing mouth sores Cardiovascular heart murmur other: Respiratory asthma cough other: Stomach/GI diarrhea constipation nausea/vomiting stomach aches Musculoskeletal joint pains joint swelling muscle weakness OTHER INFORMATION: For children under 5 years of age: Birth weight: _ Full term? _ Premature? _ How early? REASON FOR TODAY S VISIT: Failed vision screening school Dr. s office Needs new glasses Trouble reading/with schoolwork Headaches One eye drifts in or out Holds head in abnormal position Eyes shake or jiggle Other (describe briefly, state when problem began) Signature of Responsible Party: Relationship to Patient: