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«We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction – this portion of the examination ...»

NOTICE ABOUT REFRACTION

We have you scheduled for a complete eye exam today. A complete eye exam involves two

components:

1. Refraction – this portion of the examination determines the best lens correction for eyes with

refractive errors. The final refraction is the prescription given to provide the best visual acuity.

2. Medical Examination –is an extensive eye exam allowing the doctor to diagnose and treat any abnormal ocular conditions.

Please be aware that if we are filing medical insurance for today’s visit, medical insurance typically considers the refraction to be “routine vision” and this portion of the exam is not covered. If you have separate vision insurance, please let us know at the time of check in, you may be eligible for routine benefits.

 The $30.00 refraction charge is due at the time of service.

 If you are here for a surgery consultation a refraction is mandatory to determine the best refractive procedure for you.

PLEASE CHECK ONE:

( ) YES, I want a refraction today and a copy of my prescription upon request.

( ) NO, I do not want a refraction today and will not receive a written lens prescription.

Signature Please Print Name Date Mr.  Mrs.  Miss  Ms.

Salutation Please Print Name _____________________________________________ Age_______ Date of Birth____/_____/____ Sex: M F (Last) (Legal First) (M.I.) (Nickname) (Mo) (Day) (Year) Address______________________________________________ Email Address_________________________________

Email address never sold or shared City ______________________________________ State _________________ Zip ______________________________

Phone: Home # (______)_____________ Cell # (______)_________________ Work # (______)___________________

Marital Status:  Single  Married  Divorced  Widowed Social Security #_______________________________

Spouse Name ______________________________________________________________________________________

What is the reason for your visit today? List any problems or concerns you may have.________________

__________________________________________________________________________________________________

Employer___________________________________________________ Phone (______) _________________________

Occupation __________________________________ Sports or Hobbies: _______________________________________

In case of an emergency, whom should we contact? _____________________________ Phone______________________

How did you hear about us? Check as many that apply:

 Radio (station) ___________________WHEN DID YOU HEAR THE AD?_____________________________________

 Trust Dale Website  Atlanta Journal  Internet  Google  YP.com  Insurance  Unknown  Woodhams Patient Referral (Name) ________________________________  Other __________________________

Who is your regular Eye Doctor? __________________________________ Were you referred? __________________

Have you or any of your blood relatives ever been told you have: (write “S” for Self, “R” for Relative) Cataract ____ Glaucoma ____ High Blood Pressure ____ Diabetes ____ Macular Degeneration ____

–  –  –

List any allergies to medications _____________________________________________________________

Any medical conditions you’re being treated for? __________________________________________________________

Tell us the medications you are currently taking ___________________________________________________________

_________________________________________________________________________________________________

 None Previous eye surgery? Type ____________________________________ When? ____________________

–  –  –

Primary Care Physician: _______________________________________ Phone: _____________________

Have you ever passed out during a medical procedure, dental procedure, or giving blood?  Yes  No Patient Name: ____________________________________________________________________

Date: _______________________________

Insurance: List your primary insurance company first The Front Office will need copies of current insurance cards in order to process your insurance claim properly.

Name of MEDICAL Primary Carrier: ___________________________________________________________

–  –  –

Patient’s relationship to subscriber: □ Self □ Spouse □ Child □ Other Secondary MEDICAL: ______________________________________________________________________

–  –  –

It is your responsibility to check with your insurance carrier concerning their policy on routine eye exams.

INSURANCE POLICY

In order to accommodate the needs and request of our patients, we participate in numerous insurance programs. While we are pleased to be able to provide this service to you, it is impossible for us to monitor all the individual requirements of various plans. Insurance can be filed only if WEC/WLLIC are providers with your insurance plan.





 IT IS YOUR RESPONSIBILITY to contact your insurance company to verify that our doctors are participating physicians with your insurance plan. It is probable that our doctors may participate in only some plans of a particular carrier but not in all of them.

 IT IS YOUR RESPONSIBILTIY to give Woodhams Eye Clinic current/correct insurance information so that we may obtain pre-certification for surgery. If you fail to do so, you are responsible for payment in full.

 IT IS YOUR REPSONSIBILITY to read and understand your own insurance policy. Certain services and procedures may not be covered depending on your own insurance policy.

 IT IS YOUR RESPONSIBILIY to obtain a referral should your insurance policy require specialist referrals.

IN THE EVENT THAT:

 Insurance coverage is not in effect because we are not participating physicians in your plan and/or  Insurance coverage is not in effect on the date of your visit and/or  A non-covered service is performed or denied for the reason “not medically necessary”

►WE WILL BILL YOU DIRECTLY FOR ALL CHARGES RELATED TO YOUR OFFICE VISIT.

I have read, understand, and agree to this financial statement. I have filled out the Patient/Insurance Information to the best of my knowledge.

–  –  –

As Required by the Standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) I have received a copy of the Notice of Privacy Practices of Woodhams Eye Clinic and Woodhams Laser & Lens Implant Center on the date indicated below.

I understand that if any changes are made to this Notice of Privacy Practices, a revised copy of the Notice will be posted in the offices of Woodhams Eye Clinic and Woodhams Laser & Lens Implant Center.

I also understand that if I wish to receive additional copies of this Notice of Privacy Practices in the future or if I have any questions with regard to this Notice of Privacy Practices, I may contact Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center.

Patient Consent For Use And Disclosure Of Protected Health Information I hereby give my consent for Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center’s Notice of Privacy Practices provides a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of

Privacy Practices may be obtained by forwarding a written request to:

–  –  –

With this consent, Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care.

With this consent, Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

With this consent, Woodhams Clinic & Woodhams Laser and Lens Implant Center may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements.

I have the right to request that Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center restricts how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center’s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Woodhams Eye Clinic & Woodhams Laser and Lens Implant Center may decline to provide treatment to me.



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