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2 Signature

3 CONDITIONS OF REGISTRATION THE PRACTICE Sina J. Sabet, M.D. and/or its physicians, employees, agents or assignees will hereafter be referred to as The Practice. CONSENT FOR TREATMENT The undersigned hereby consents to the administration of such medical treatment, diagnostic and/or therapeutic procedures and surgery as required by the physician rendering care for themselves and/or their child (ren). The procedures may include, but are not limited to, surgery, laboratory and x-ray procedures. HIV/HEPATITIS B & C VIRUSES TESTING NOTIFICATION In accordance with Virginia law, any patient to whose body fluids a healthcare worker has been exposed will be deemed to have consented to HIV/HEPITITIS B & C TESTING. In all other cases, the patient shall have the right to informed consent or refusal for HIV/HEPITITIS B & C TESTING. We do not randomly test for HIV. AUTHORIZATION & ASSIGMENT OF INSURANCE BENEFITS I do hereby authorize The Practice to apply for benefits for services rendered to myself or minor child (ren) under Medicaid, Medicare, or any health insurance policies/programs providing benefits and do hereby also assign and authorize payment of benefits from my (our) insurance company to The Practice (including benefits payable under Title XVIII of the Social Security Act and/or any other governmental agency.) I irrevocably authorize all such payments to The Practice. I authorize The Practice to contact the employer or insurance company regarding insurance information, existence of insurance and coverage of my (our) benefits. RELEASE OF MEDICAL INFORMATION I authorize The Practice to release any and all of my or my minor child(ren) s medical records and/or other information and records required by my (our) insurance company or its designated review agents who provide insurance benefits on my (our) behalf, including if applicable, my employer and/or employer s workman s compensation insurance company, the Social Security Administration, the Health Care Financing Administration or The Centers for Medicare and Medicaid Services(CMS), needed to determine benefits and to process insurance claims and secure payment of benefits to either the insured or to The Practice; and authorize any hospital, lab, physician, or other healthcare provider and/or their staffs and to release my or my minor child(ren) s medical records and/or other records and information on myself or my minor child(ren) to The Practice as required for payment of benefits and/or required for medical or any other reasons; and authorize The Practice to release the above mentioned records for any of the above reasons. I agree to pay any applicable charges for having records copied. Such charges for records do not to exceed $.50 per page for the first 50 pages and $.25 per page thereafter in addition to a $10.00 regular postage/handling fee. I further agree to pay a $35.00 form fee for each form I require to be completed by The Practice. REFERRALS AND AUTHORIZATIONS If I have an insurance plan that requires any referrals, pre-certifications or authorizations I understand that it is my responsibility and not The Practice s to obtain approval from my insurance plan for medical services and/or procedures prior to such medical services and/or procedures being rendered. Some insurance companies may take up to 48 hours or more to obtain a referral. Additionally, if any aforementioned procedures are not done and medical services and/or procedures are rendered without the proper insurance approval, I understand that this may cause reduced or rejected coverage for which I will be held responsible and that any of these aforementioned actions do not guarantee that my insurance company will pay for the claims. Any denial of claims is between the policyholder/subscriber and their insurance. I (we) agree to inform The Practice immediately of any change in insurance coverage and/or benefits and change of personal information. I understand medical services may not be rendered without the proper referral on file. FINANCIAL AGREEMENT I agree that payment in full is due at the time of treatment. I the undersigned (jointly and severally if more than one) further agree that I am legally obligated and responsible and do hereby guarantee payment for all charges incurred by myself, my children, step children or any other extended family members, including but not limited to grandchildren, nieces and nephews. I also understand that I (we) may be billed separately for services rendered by other professionals including, but not limited to other physicians, radiologists, and laboratory work, as appropriate and in accordance with the services rendered. The Practice will file for insurance benefits and accept payments per The Practice s contractual agreements with the insurance company. Any questions or disputes concerning insurance coverage or payment of benefits are a matter between the insurance subscriber/policyholder and the insurance company. Any assistance in this matter granted by The Practice is given strictly as a courtesy and implies no responsibility on The Practice s part for filing, follow through or conformation.. I agree to pay a $25.00 fee for missed appointments that are not cancelled at least 24 hours in advance. Should any balances arise due to insurance co-payments, co-insurance, deductibles, termination of coverage, not adding a dependent to insurance plan, non-payment at time of service and/or any other reason I agree to pay all charges within 30 days of services rendered. I agree that if for any reason a check is returned on my account I will be responsible for a $25.00 returned check fee in addition to the original fees for services. Interest of one and one-half percent per month, eighteen percent per annum, will be charged on all accounts over 30 days. If the balance is not paid within the 30 days or if agreed upon payment arrangements on my (our) account are not made, I authorize the practice to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance and to notify the credit bureaus of my (our) delinquencies. I understand that this will affect my (our) credit rating. If this account is placed for collection, I agree to pay one-third of the unpaid principal and interest as a collection fee, plus court costs and interest in the amount of one and one-half percent per month, beginning 30 days after the monies have become due or expenses have been incurred. Any expenses incurred by such collection actions, including maximum allowed interest, shall become an additional liability for which I (we) assume full responsibility. COPY OF SIGNATURE I permit a copy of this authorization and signature to be used in place of this original on all insurance claim submissions and for the release of any medical records and/or other records and information, as stated herein, whether manual, electronic or telephonic. CERTIFICATION I certify that the information I have reported with regard to my (our) insurance coverage is correct and that the above be honored by my (our) insurance carriers. This certification will also apply to application for benefits under Title XVIII of the Social Security Act and/or any other governmental agency, if applicable. I also certify that I have read the forgoing and understand and fully accept the terms therein. Signature Print Name

4 Signature Print Name

5 INFORMATION REGARDING DILATING EYE DROPS Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time, which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it s best if you make arrangements not to drive yourself. Dilation takes time after inserting drops to take effect. This means that full a dilated examination will take about 90 minutes. If your time is limited and less than the required time, please let us know and we can focus the exam on the main reason you are having and perhaps reschedule the dilation at your convenience. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I hereby (AUTHORIZE / NOT AUTHORIZE) Dr. Sina J. Sabet and/or its physicians, employees as may be designated by him to administer dilating eye drops. The eye drops are necessary to diagnose my condition. Patient Signature (or person authorized to sign for patient) Practice Representative CHART STAENTATION DILATION: 1. Do you authorize to receive drops today? NO or YES If NO: Please understand that the doctor may not be able to detect all medical conditions affecting the eyes. Would you like to reschedule the dilation at a later time? NO or YES 2. Have you had dilating drops before? NO or YES 3. Bad reaction? NO or YES 4. Allergies to the drops? NO or YES 5. On heart or blood pressure medication? NO or YES 6. Are you pregnant or breastfeeding? NO or YES 7. Have you been told you have narrow angle glaucoma in the past? NO or YES EXAM: Are you here for an eyeglasses exam? Yes No Are you here for a contact lens exam? Yes* No *If you receive a single vision contact lens exam there is an additional $80.00 fee. *If you receive a multifocal contact lens exam there is an additional $ fee. *If you receive a keratoconus contact lens exam there is an additional $ fee. *YOUR INSURANCE OR VISION PLAN MAY NOT COVER THIS FEE. THE PATIENT WILL THEN BE RESPONSIBLE FOR THIS ADDITIONAL FEE. Patient (or person authorized to sign for patient) Practice Representative