Important Insurance Information Please review and sign below so we can process your claim accurately and efficiently

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Beatrix Gallagher
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2 Important Insurance Information Please review and sign below so we can process your claim accurately and efficiently Our staff will be happy to assist you in submitting and processing your claims, however, it is ultimately your responsibility to know what your own medical or vision plan covers. Please check your policy to determine your coverage prior to your exam. Will my exam be covered by insurance? Most eye exams, whether for a specific eye problem or for general vision care, will be covered at least in part by your primary medical insurance. As with any medical visit, your usual copays and deductibles will apply. Some services, including refraction and contact lens exams, may not be covered. For insurance purposes, eye examinations are classified as either Medical or Routine. Your medical history, current symptoms, and examination findings will determine how your visit is coded. What is a Medical eye exam? Your visit will be coded as a medical exam if any of the following apply: You have any symptoms related to the health of the eyes, such as headaches, eye pain, itching, tearing, redness, dry eye, sudden vision changes, double vision, light sensitivity, floaters, etc. You have a known medical eye condition, such as cataracts, glaucoma or macular degeneration or you have a family history of glaucoma You have a history of diabetes, high blood pressure, or certain other medical diseases You are diagnosed with a medical eye condition during your exam During a medical eye examination, the doctor will evaluate the reason for your symptoms and determine if any treatment or additional testing is required. What is a Routine eye exam and will my insurance cover it? If none of the above apply to you, this constitutes a routine well- vision exam. During a routine exam, your eyes will be examined for any needed visual correction (glasses, etc.) and screened for potential indicators of eye disease. Please be aware that many insurance plans do not cover routine eye exams and will only cover your exam if you have medical symptoms related to the eyes or you are diagnosed with a medical eye condition. Some insurance plans will cover a routine exam once every 1 or 2 years, depending on the policy. You must notify our staff in advance of your exam if your plan will cover a routine eye exam. If you are unsure, we recommend that you check with your insurance company prior to your exam. Once we submit a claim, it cannot be changed from medical to routine or vice versa. Refraction: What is it and does my insurance cover it? Refraction is the diagnostic procedure used to determine your best- corrected vision. This can be achieved at all ages using different techniques, but usually involves looking through a device with adjustable lenses while the doctor has you read letters on an eye chart. Refraction must be performed in order for the doctor to prescribe glasses. For some medical conditions and for most children who have been referred after a failed vision screen, refraction is needed even if glasses are not prescribed. Unfortunately, the majority of insurance companies (including Medicare) do not cover this essential procedure. If your insurance does not cover refraction, you will be billed accordingly. The current fee for refraction is $75 (subject to change) and is due on the day of service.

3 Does Stamford Ophthalmology accept Vision Plans? We do not participate with most vision plans; however, Dr. Pribis does accept EyeMed and Davis Vision for routine eye examinations only. If you have any medical symptoms related to the eyes, or if the doctor diagnoses any medical condition during your exam, your claim must be processed through your regular medical insurance. You may inquire at the optical shop to see if your vision plan can help cover the cost of glasses. Will insurance cover my contact lens examination? Medical insurance plans do not consider contact lenses medically necessary and will not typically cover contact lens fittings or annual contact lens examinations. Please review our contact lens agreement for details regarding our fees and policies. What if I don t have any medical insurance? If you do not have any medical insurance, payment for any services provided is expected in full on the day of your visit. You may inquire with our staff regarding approximate fees Please check ONE and sign below: Please submit my claim to my primary medical insurance as a medical eye exam. I understand that my usual copays and deductibles will apply and I will be responsible for any uncovered services. My medical insurance plan will cover a routine well- vision eye exam. I have no symptoms related to the health of my eyes and no known medical eye conditions. I understand that if I am diagnosed with a medical condition during my exam, or if any additional testing is required, my claim cannot be considered routine and will instead be coded as a medical eye exam. Please be advised that this cannot be changed once your claim has been submitted to your insurance, so please be sure of your coverage prior to your exam. I have EyeMed / Davis (circle one) and would like Dr. Pribis to perform a routine eye exam. I understand that if I am diagnosed with a medical condition during my exam, or if any additional testing is required, my claim must be processed though my regular medical insurance. I do not have any medical insurance at this time. I understand that I will be responsible for payment in full on the day of service. Patient Name: Guardian (if patient is under 18): Signature: Date: / /

4 Stamford Ophthalmology Financial Policy The doctors and staff of Stamford Ophthalmology are committed to providing you with the best possible care. Your clear understanding of our financial policy is important to our professional relationship. Full payment is due at the time of service or on receipt of statement after insurance payment has been made to Stamford Ophthalmology. Insurance co- payments, deductibles, refraction fees and fees for any other non- covered services are due at the time of service. A $25 administrative fee will be added for any applicable payments not made at the time of service. Due to recent changes in health care law, we are not permitted to waive copays or deductibles. If, after reasonable attempts are made at obtaining payment for outstanding bills, your account is turned over to collections, you will be responsible for an additional 30% finance charge. Forms of payment accepted: Cash, Check, Visa, MasterCard, American Express and Discover. There is a $35 charge for returned checks. Cancellation policy / Missed Appointments: Please note that failure to provide 24 hours notice of appointment cancellation may result in a $50 cancellation fee. Unaccompanied Minors: Minors under the age of 18 must be accompanied by a parent or authorized guardian. Regarding insurance: If you have insurance, we will help you receive maximum benefits. If you have an indemnity plan or if we do not participate with your insurance, we will be happy to provide you with a copy of your receipt so that you can be reimbursed by your insurance company. Insurance is a contract between you and your insurance carrier. We are typically not party to this contract. If we are, we will inform you and handle the claim according to our agreement with the insurance company. We file insurance claims as a courtesy to our patients and will not become involved in disputes between you and your carrier regarding deductibles, co- payments, covered charges, and secondary insurance or other matters regarding reimbursement. We do not routinely file secondary insurance claims, however, we will provide a receipt so that you can be reimbursed. There has been a continual increase in private insurance companies requiring pre- admission certification for outpatient procedures and some office visits. It is your responsibility to be aware of the requirements of your insurance policy and alert us prior to any outpatient procedures. Failure to do so may result in partial or complete denial of benefits if your insurance policy subsequently determines the services not to be payable. You are responsible for the timely payment of your account Medicare / Medicaid / Workman s Compensation: If you are covered by Medicare, Medicaid, Workman s Compensation, or any other government sponsored program, please discuss your payment situation with our office staff prior to the date of service. Thank you for taking the time to understand our financial policy. Please inquire with our office staff if you have any questions or concerns regarding our professional fees or financial policies. I understand and agree to the above financial policy of Stamford Ophthalmology. I understand that my signature requests that payment be made to Stamford Ophthalmology and authorizes the release of medical information necessary to pay the claim with the approved claim forms or electronically submitted claims. My signature authorizes the release of the information to the company shown in my file. Name: Signature: Date:

PATIENT REGISTRATION. Patient s Name: (Last) (First) Home Address: City State Zip. Home Phone: Cell Phone: Work Phone:

PATIENT REGISTRATION. Patient s Name: (Last) (First) Home Address: City State Zip. Home Phone: Cell Phone: Work Phone: PATIENT REGISTRATION Date: Patient s Name: (Last) (First) Home Address: City State Zip Home Phone: Cell Phone: Work Phone: Email Address: May we call you at work? Yes No Date of Birth: Sex: M / F / Other