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«Welcome to the East Bay Eye Center MEDICAL CORPORATION • Diagnosis and treatment of glaucoma • Cataract surgery with the latest lens implants • ...»

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Welcome to the East Bay Eye Center

MEDICAL CORPORATION

• Diagnosis and treatment of glaucoma

• Cataract surgery with the latest lens implants

• Refractive Surgery

• Functional, cosmetic and reconstructive surgery

Todd D. Severin, M.D.

• Diagnosis and management of medical vision problems

Diplomate American Board

of Ophthalmology • Comprehensive eye examinations Glaucoma, Anterior Segment Surgery • Treatment for dry eyes

• Botox and facial rejuvenation Sanford L. Severin, M.D., F.I.C.S. • Neuro-Ophthalmology Diplomate American Board of Ophthalmology Medical Ophthalmology Thanks to the marvels of the internet and e-mail, we are able to help you save time at your next appointment with East Bay Eye Center.

Viet H. Ho, M.D.

Enclosed are the necessary forms for your upcoming appointment.

Diplomate American Board of Ophthalmology We advocate regular medical examinations to safeguard the health of Oculoplastic, Orbital and your eyes. New diagnostic and treatment techniques allow us to Reconstructive Surgery detect abnormalities early so that successful treatment can be initiated. Our initial examinations are very thorough, so allow two Kimberly P. Cockerham, M.D.

hours for your appointment for a dilated examination. Please bring Diplomate American Board your eye wear and a list of all of your eye drops and oral medications, of Ophthalmology including over-the-counter medications and supplements.

Neuro-Ophthalmology and Orbital Surgery

Hours & Scheduling:

The doctors of the East Bay Eye Centers see patients, by appointment Aimée R. P. Edell, M.D.

only, Monday through Friday. If you are not able to keep your of Ophthalmology Corneal Surgery and Disorders of appointment, please give us 24 hours notice. We bill $50.00-$200.00 The Anterior Segment for appointments that are missed without notice. If you are running late, please call the office as soon as possible so that we may attempt to accommodate your needs.

Edward A. Laubach, O.D.

–  –  –

Who is my PCP?

Your “PCP” is your Primary Care Physician. We are your “Specialist” Physicians. If you have an HMO or POS plan (indicated on your insurance card) you will need to select a PCP. Some PPO and EPO plans also require PCP’s and doctors within your network.

Which Providers can I see on my insurance plan?

If you have an HMO plan, please check which “Medical Group” you are assigned. This is usually found on the front of your insurance card near your PCP’s name. An “IPA” is another system that your insurance assigns to you in place of a “Medical Group”. The function is the same.

Each HMO insurance plan assigns its patients to a particular Medical Group or IPA. Individually, all of your Providers including Specialists must be contracted with your assigned Medical Group. Your PCP should be able to select the Specialists that you are eligible to visit. Your PCP also provides you with an “Authorization” to receive care from a Specialist. Since we are a Specialist office, you will need to have an Authorization for your care with our specialist. It is your responsibility to obtain an authorization from your PCP if you have HMO or POS coverage. Your Specialist is not required to obtain the authorization for your visits.

Please inform our receptionists whenever there is any change in your insurance. This is important to you. If you change insurance and we provide you with service for which we are NOT providers, you are personally responsible for the office visit.

Ask Yourself:

• Do I need an authorization for my upcoming office visit to East Bay Eye Center?

• Have I recently gotten a new insurance card?

• Is my Medical Group the same?

• Do I need to call my PCP or Insurance Company with any Questions?

Please take a moment and learn about your insurance coverage.

We are concerned about continuing to provide you with the best possible medical eye care possible and your knowledge about your coverage will help us to do our job

–  –  –

1st FORM: Patent registration (three pages) 2nd FORM: Financial Policy (two pages) 3rd FORM: Lifetime Beneficiary:

(WE WILL NEED YOUR INSURANCE CARD AT THE TIME OF THE

APPOINTMENT, THIS WILL REPLACE THE INFORMATION ON THIS

FORM BECAUSE YOU ARE THE BENEFICIARY).

OR Use the MEDICARE with SUPPLEMENTAL INSURANCE form.

A photocopy will be taken at the time of your appointment

WE CAN NOT SEE YOU WITHOUT YOUR CARDS IN HAND

4th FORM: NOTICE OF PRIVACY PRACTICES (HIPAA).

(This form is yours to keep).

5th FORM: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF

PRIVACY PRACTICES (HIPAA). Please print your name, sign, and date (This is acknowledging that you received the 4th form)

–  –  –

If you need to cancel, for any reason,

WE HAVE A 24 HOUR ADVANCE CANCELLATION NOTICE REQUIREMENT





A MEDICAL SPECIALIST HAS BEEN SCHEDULED TO BE HERE FOR YOUR NEEDS

THUS A $50.00 MINIMUM OFFICE FEE WILL BE CHARGED FOR MISSED APPOINTMENTS ($100.00-$200.00 fee for multiple appointments scheduled in the same visit, i.e. testing with your doctor visit, etc.)

–  –  –

PREFERRED LANGUAGE______________________ RACE:_________________ETHNICITY:_________________

ADDRESS:_________________________________________________________________________________________

STREET CITY STATE ZIP

HOME PHONE: (____)______________ CELL PHONE: (_____)______________ WORK PHONE: (_____)_____________

EMAIL _________________________________________

EMPLOYER:_______________________ OCCUPATION:_______________ MAY WE CONTACT YOU AT WORK? Y / N EMERGENCY CONTACT PERSON:____________________________________ PHONE: (_____)______________

IN CASE OF MINOR/DISABLED PERSON PLEASE LIST NAME OF RESPONSIBLE PARTY:

NAME:____________________________________ RELATIONSHIP:________ PHONE: (____)_______________

ADDRESS:__________________________________________________________________________________

STREET CITY STATE ZIP

WHO MAY WE THANK FOR REFERRING YOU?_____________________________________________________

PRIMARY CARE PHYSICIAN:________________________________________ PHONE: (____)_______________

OPTOMETRIST/VISION CENTER:____________________________________ PHONE: (____)________________

INSURANCE INFORMATION (ALL INFORMATION BELOW IS REQUIRED IN ORDER TO BILL YOUR INSURANCE, THANK YOU)

PRIMARY INSURANCE COMPANY :_______________________HMO GRP NAME (IF APP):__________________

SUBSCRIBER NAME:__________________________ SUBSCRIBER’S ID# and/or SS#:______________________

SUBSCRIBER DATE OF BIRTH:____/____/____ SECONDARY INSURANCE COMPANY :_____________________HMO GRP NAME (IF APP):__________________

SUBSCRIBER NAME:__________________________ SUBSCRIBER’S ID# and/or SS#:______________________

SUBSCRIBER’S DATE OF BIRTH:____/____/____  Patients are required to present their insurance identification cards at the time of each visit. If your insurance requires a Referral or Authorization, it is your responsibility to notify our office at the time of making your appointment. We bill your insurance as a courtesy for you.

 It is the policy of East Bay Eye Center to collect all CoPayments at the time of each service. If a patient does not have proof of insurance, full payment is required at the time of service.

–  –  –

Please explain any of the above as well as other history or conditions:_____________________________________________

List all Eye Drop Medications:_______________________________________________________________________________

PERSONAL MEDICAL HISTORY (Please complete Review of Systems form) Any other illness not listed (Please Specify):__________________________________________________________________

Please list all prescription medications and / or all vitamins and over the counter remedies currently taking. (Please include blood thinners like aspirin and anti-inflammatory agents)_________________________________________________________

Allergies to Medications: Yes_____ No_____ Please List________________________________________________________

Do you have a Pace Maker/Cardiac Defibrillator? (Please state which)______________________________________________

List all surgical procedures/dates:____________________________________________________________________________

FAMILY HISTORY (Check all that apply and what family member)

–  –  –

Our fees cannot always be determined in advance, since they depend on services rendered.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.

PATIENTS WITH INSURANCE

We require you to show your current insurance cards at each visit.

Although we bill your insurance company or Medical Group for services rendered, you are financially responsible for all services rendered. If payment has not been received within sixty (60) days of billing your health plan or Medical Group, we will contact you for assistance. Should your health plan or Medical Group deny coverage for any reason, you will be responsible for payment in full within thirty (30) days of your billing statement.

MEDICARE We will bill Medicare, secondary and tertiary health plans for you. You must, however, supply us with the most up-to-date and correct information at the time of your visit. You will be responsible for your deductible and co-pays. If you do not have a supplemental insurance, or if you do not bring your card, you will be required to pay the 20% that Medicare does not, at the time of your visit.

PRIVATE INSURANCE

Insurance is a contract between you and your insurance company. We file insurance claims as a courtesy to our patients. We cannot become involved in disputes between you and your insurance company regarding deductibles, co-payments, etc. other than to supply factual information as necessary. You are responsible for the timely payment of your account. If you have a co-pay or deductible, plan to pay it at the time of your visit.

HMO/PPO

CO-PAYMENT AND DEDUCTIBLES ARE DUE AT THE TIME OF YOUR VISIT. YOU MUST HAVE A

CURRENTAUTHORIZATION/REFERRAL AT THE TIME OF YOUR VISIT.

Medicare/Medi-Cal or State Medi-Cal We are no longer a Medi-Cal providers. If you choose to be seen by our Doctors, you will be charged for your examination. Medicare-Medi-Cal patients will be charged the 20% that Medicare does not cover. State Medi-Cal patients are responsible for the entire amount. Payment is required at the time of service, we do not bill.

–  –  –

I understand that there will be a minimum $50.00 charge for any missed office appointments without a 24-hour notice. ($100.00-$200.00 fee for multiple appointments scheduled in the same visit, i.e. testing with your doctor visit, etc.)

SURGERY CANCELLATION FEES

There is a $300.00 cancellation fee if you have to cancel or reschedule your surgery. This fee is waived if it is cancelled by your physician for medical reasons. Scheduling surgery is extremely time consuming, therefore we ask that you are sure of your dates prior to committing to them.

LATE FEES There will be an additional 10% charged for unpaid balances after 60 days and an additional 15% after 90 days. After 120 days the balance will go to collections. These charges are enforced after payments from insurance.

FORM FEES Due to the large number of forms received by our office we have been forced to charge for their completion. An example of charges is listed below.

FORMS FEE Private or Miscellaneous forms, (including DMV forms)

Specialty letters per patient request

(Grievance, appeals or letters of medical necessity) Copies of testing………………………………………………………………….Black & White $5.00,…Color $25.00 *Fees for copies of your records are found in the HIPAA Policy. This includes sending copies to other doctors.

RE-BILLING FEES

If we are not provided with the most current insurance information, and we have to re-bill, there will be an additional $20.00 charge.

We accept cash, checks and most major credit cards (we do not accept American Express) Thank you for understanding our financial policy.

Please let us know If you have any questions or concerns.

I, THE UNDER SIGNED, HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.

Responsible Party:_________________________________________Date:______________________

–  –  –

I request that payment of authorized Medicare benefits be made on my behalf to East Bay Eye Center Medical Corporation for any services furnished to me by East Bay Eye Center Medical Corporation. I authorize any holder of medical information about me, in order to determine these benefits or benefits payable for related services, to be released to the Health Care Financing Administration and its agents.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. My signature authorizes releasing of the information to the insurer or agency shown. In assigned cases, East Bay Eye Center Medical Corporation agrees o accept the charge determination of the carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the carrier.

–  –  –

I understand that if I have a Medi-Gap (Secondary Insurance) policy or other health insurance, my signature authorizes release of the information to the insurer or agency.



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