Thank you for trusting us with your vision. We care about you and will do everything possible to help you see clearly once again.

Transcription

1 Thank you for choosing BVA Advanced Eye Care for your cataract evaluation. We look forward to seeing you during your visit and are excited to help restore your vision. Over the last 20 years cataract surgery has evolved to be one of the safest and most reliable methods to restore vision. The advancements in medical technology now allow new options for patients considering cataract surgery who also want to become less dependent on glasses. The purpose of this letter is to let you know that you will need to make a decision following your evaluation about the type of lens implant that you would like. Depending on the complexity of your prescription, certain lens implants may be better suited to help you become less dependent on glasses. We will discuss your options and make recommendations based on your prescription and your lifestyle. There are also new options in the way cataract surgery is performed. Traditional cataract surgery has been a tried and true procedure that has been perfected for many years. To improve the precision of the surgery, several of the steps of traditional cataract surgery can now be aided by the use of a femtosecond laser. This technology can help with the predictability of the visual outcomes when combined with our specialty lens implants. We have enclosed information about both the lens implant options and the laser cataract surgery option. Please review these prior to your appointment to help us determine the best approach to cataract surgery if needed. Please be aware that insurance does cover traditional cataract surgery but not the upgraded options. The exact cost will be discussed with you by our patient counselors. Thank you for trusting us with your vision. We care about you and will do everything possible to help you see clearly once again. Larry R. Henry, O.D., F.A.A.O., Diplomate ABO Clinical Director, BVA Advanced Eye Care

2 Traditional Cataract Surgery Our eye functions much like a camera. The natural lens inside our eye focuses images onto the back of the eye so we can see clearly, much like the lens of a camera focuses images onto film for a clear picture. At birth, our natural lens is clear, but as we age it yellows, hardens and may become cloudy. This condition is called a cataract, and is a result of the natural aging process. As the natural lens becomes cloudier, vision becomes more blurred. Traditional cataract surgery is one of the most routinely performed surgeries in the United States. It has a very safe and effective outcome when performed by a skilled surgeon. Surgery is performed in a fully-accredited outpatient surgery center. Patients need not expect to stay at the surgery center for more than a couple of hours. Prior to surgery, patients are given a relaxant to enhance calmness. Patients do not have to remain under anesthesia and should neither see nor feel any part of the surgery. Through a microincision, the cataract is dissolved and removed from the eye using ultrasound technology. The cataract is then replaced with a foldable lens implant through the original micro-incision. The incision is self-healing and heals without stitches. Since no eye patch is used, the eye can be used for vision immediately after surgery. Because the pupil will still be dilated after surgery, your eyesight may be somewhat blurry but will gradually improve over the next few days. After a short stay in the outpatient recovery area, you will be ready to go home. You are required to have someone drive you home and you should plan to have a responsible adult remain with you for a few hours following surgery. Monofocal Lens Traditional cataract surgery uses a standard single-focus lens, or monofocal, lens implant to replace the clouded natural lens to help improve vision. Patients who have a simple nearsighted or simple farsighted prescription may only need reading glasses following traditional cataract surgery. Full-time glasses, however, may still be needed for patients whose prescriptions are more complex.

3 Patients with more complex prescriptions, known as astigmatism, will still need to wear full-time glasses following traditional cataract surgery. Astigmatism is due to an irregular shape of the cornea. This irregular shape of the cornea can cause blurring, distortion or even doubling of the vision. Cataract surgery can be customized in two ways to surgically correct astigmatism depending on its severity: Mild Astigmatism can typically be reduced with a simple surgical procedure known as Astigmatic Keratectomy (AK). AK is performed during the cataract surgery to reshape the cornea into a more rounded surface. Moderate and higher amounts of astigmatism can be corrected with a Toric lens implant, a lens implant specifically designed to correct astigmatic prescriptions. The toric lens implant must be carefully positioned during surgery to compensate for the irregular-shaped cornea. Although custom cataract surgery for astigmatism improves the patient's vision in the distance, there will still be a need for reading glasses.

4 Multifocal and Accommodating IOLs are designed to eliminate your need or reduce your dependence on glasses after cataract surgery compared to the traditional monofocal IOLs. They are designed to provide both distance (far away) and near (close up) focus at all times. Multifocal IOLs work differently from bifocal eyeglasses. With bifocals, you look through the top part of the lens for distance vision and the bottom part for near vision. A multifocal IOL has concentric rings that help your brain select the right focus automatically. Like wearing bifocals, this can take time. Your vision without glasses usually improves gradually over the first year. The rings of multifocal IOLs can create halos - a glow around lights at night. This depends partly on the size of your pupils, the area where light enters your eye. The amount of light affects halo size. With time, your brain gradually adapts, and most people with multifocal IOLs feel this effect is minor. An Accommodating IOL is one that can move or change its shape in the eye. By doing this it changes its power so that it can focus from near to far. The only accommodating lens currently available is the Crystalens. This is wonderful technology and is very useful for those people who want the crispest distance vision as well as an excellent ability to see intermediate distance which includes things like the computer screen, grocery store shelves, and auto gauges. In fact, much of our time is spent looking at things in the intermediate range. Most people who receive the Crystalens in both eyes are thrilled with the quality and range of vision. The one drawback of this lens is that some people will still need glasses for very close vision and when trying to read the smallest print. TECNIS Symfony Crystalens

5 Just as you have options when it comes to choosing the lens that you receive during cataract surgery, you also have the option of choosing the technology that is used to perform the procedure. This means you have a choice between traditional cataract surgery or cataract surgery with the assistance of laser technology. For patients that want cataract surgery performed with the precision and accuracy of a laser, BVA is proud to offer the CATALYS Precision Laser System. Using femtosecond laser technology, the CATALYS System is able to automate some of the more technically demanding steps of the traditional cataract surgery. This can make laser-assisted cataract surgery procedures more predictable and precise, specifically in three areas: 1) The laser makes more precise incisions during cataract surgery to gain access to the cataract lens. 2) The laser pre-softens the cataract prior to removal to minimize the need for ultrasound energy during the surgery. 3) The laser can be used for more precise and predictable astigmatism correction at the time of cataract surgery by resculpting an irregular corneal surface. Re-sculpting reduces the need for distance glasses for patients with complex prescriptions. Please Note: Most cataract surgery upgrades are considered a premium refractive surgery by insurances and require out-of-pocket charges. We will be happy to discuss this with you during your visit, as well as flexible payment plans.

6 Read enclosed cataract surgery informed consent Discontinue contact lens wear prior to your evaluation for: Daily Wear 1 week Extended Wear 2 weeks Toric Contacts for Astigmatism 2 weeks Hard or Gas-permeable 4 weeks Bring the following: Insurance Cards Insurance authorization if required Photo I.D. Filled-out Patient Data form Filled-out Health History form List of current medications Sunglasses Plan for 1½ to 2½ hours for the comprehensive testing and evaluation Your eyes may be dilated and it is recommended to bring a driver You will meet with a Surgery Counselor to answer questions and schedule your surgery date Do not eat or drink 6-8 hours prior to your surgery Wear comfortable clothing including a button front shirt Do not wear makeup Bring post-operative medications No driving for hours No lifting over 20lbs for 1 week (normal bending and light lifting is permitted) No makeup for 1 week No swimming, Tennis or Golf for 1 week Bring your post-operative medications Lifestyle Lens Implant Patients - payment due for post-operative care

7 BVA Patient Data Sheet Account # First Name: Middle Initial: Last Name: Address: City: State: Zip: of Birth: Age: Marital Status: M S D W Sex: M F Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) SS# Driver s License#: Race: Ethnicity: Preferred Language: Follow-up Preference: Phone Mail Optometrist: Referring Physician: Primary Care Physician: How did you hear of BVA? (circle) Family or Friend Insurance Plan Optometrist TV Ad Other Employer: Employer Address: City/State/Zip: Insurance Information Primary Insurance: I.D.#: Group #: Secondary Insurance: I.D.#: Group #: Primary Insured/Responsible Party Information (if different from patient information) Name: Relationship to patient: Address: City: State: Zip: of Birth: Age: Marital Status: M S D W Sex: M F Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) SS# Visit Information Reason for your visit? If this visit is due to an accident, please provide accident date: What Pharmacy do you use? Privacy Information Pharmacy Address: Relative/Friend whom we may contact in case of an emergency and/or about your visit if necessary (HIPPA compliance): 1) Relationship: Phone#: 2) Relationship: Phone#: I certify that I have been provided the BVA Patient Information Privacy Notice: Patient Signature Authorization of Care I authorize BVA to examine me and perform such tests and procedures as are reasonable and necessary in the diagnosis and treatment of my care. If I am not the patient, but instead signing on behalf of the patient, I further certify that I am legally authorized to sign on the patient s behalf. Patient s Signature Representative s Signature Relationship of Representative to patient

8 BVA Patient History Patient Name: DOB: Please Circle YES or NO to indicate if you have had any of the following: Eye History YOU: FAMILY MEMBER: Blindness... Yes No Yes No Relationship: Cataracts... Yes No Yes No Relationship: Diabetic Retinopathy... Yes No Yes No Relationship: Glaucoma... Yes No Yes No Relationship: Macular Degeneration... Yes No Yes No Relationship: Retinal Detachment... Yes No Yes No Relationship: General History YOU: FAMILY MEMBER: Arthritis... Yes No Yes No Relationship: Cancer... Yes No Yes No Relationship: Diabetes... Yes No Yes No Relationship: Heart Disease... Yes No Yes No Relationship: High Blood Pressure... Yes No Yes No Relationship: High Cholesterol... Yes No Yes No Relationship: Kidney Disease... Yes No Yes No Relationship: Lung Disease... Yes No Yes No Relationship: Lupus... Yes No Yes No Relationship: Stroke... Yes No Yes No Relationship: Thyroid... Yes No Yes No Relationship: AIDS/HIV... Yes No Bleeding/Clotting... Yes No Ever taken Flomax?... Yes No Hepatitis (Type )... Yes No Sleep Apnea... Yes No Other: Social History Current Occupation/Hobbies: Are you pregnant?... Yes Do you smoke?... Yes No Packs per day? Do you drink alcohol?... Yes No Alcohol use: Do you have a Chemical Dependency?...Yes No Drug use: Do you drive?... Yes No No Do you have visual difficulty when driving/or problems with night vision?...yes Do you wear contacts?... Yes No Type/hours per day? Do you wear glasses?... Yes No No -Page 1 of 2-

9 BVA Patient History Patient Name: DOB: Please Circle YES or NO to indicate if you have had any of the following: Loss of Vision... Yes No Blurred Vision... Yes No Fluctuated Vision... Yes No Distorted Vision... Yes No Loss of Side Vision... Yes No Double Vision... Yes No Dryness... Yes No Mucus... Yes No Redness... Yes No Sandy or Gritty Feeling... Yes No Burning or Itchy... Yes No Foreign Body Sensation... Yes No Excess Tearing/Watering... Yes No Glare and Light Sensitivity... Yes No Eye Pain or Soreness... Yes No Infection of Eyelid... Yes No Tired Eyes... Yes No Crossing Eyes... Yes No Lazy Eye... Yes No Drooping Eyelid... Yes No Please List All Current Medications and Dosage (including EYE drops): Please List Your Height: Weight: [Information required for surgery patients.] Please List All Known Allergies: Please List All Past Surgeries & Surgery s (including EYE surgeries): -Page 2 of 2-

10 CONSENT FOR DILATING EYE DROPS WHILE UNDER THE CARE OF BVA DOCTORS A variety of eye drops may be administered during the course of your eye examination. Dilating drops enlarge the pupils of the eye to allow for the examination of the inside of your eye. These drops usually cause blurred vision. The length of time vision will be blurred and the degree of eyesight impairment varies from person to person. It is not possible for your doctor to predict how much or how long your vision will be affected. Driving even in low light conditions may be difficult or impossible after an examination with dilating drops, and, if possible you should not drive yourself afterwards. Instead, we strongly suggest you make alternate arrangements for transportation after your examination. If you choose to drive yourself, you acknowledge that you understand the risks and accept full responsibility for any injuries to yourself or others. Also, we strongly suggest you use sunglasses to reduce your increased sensitivity to light while driving. Although uncommon, the potential for adverse reactions from eye drops does exist, such as acute angle-closure glaucoma, which may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. You hereby authorize BVA doctors and/or assistants to administer dilating eye drops or other eye drops during the course of your treatment. You understand that these eye drops are necessary to diagnose your condition. You further understand and acknowledge that you have been warned of the potential risks that dilating eye drops may have on your ability to drive and will take appropriate steps to reduce this risk by not driving immediately after your eyes have been dilated or by wearing sunglasses while driving. Patient Signature (or authorized representative)

11 ASSIGNMENT OF MEDICARE BENEFITS PATIENT NAME: I request that payment of authorized Medicare benefits be made on my behalf to BVA Advanced Eye Care for any service furnished to me by a physician of the group. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits payable for related services. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier and I am responsible for the Medicare deductible, co-insurance or the 20% Medicare does not pay, and for any non-covered services. My signature below further verifies that I have not joined an HMO or other entity in which my Medicare Benefits have been relinquished. Patient Signature MEDIGAP OR OTHER SECONDARY INSURANCE I request that the payment of authorized Medigap or other Insurance benefits be made either by me or on my behalf to BVA Advanced Eye Care, or any physician of that group, for services provided to me by a physician of the group. I authorize any holder of medical information about me to release it to my Medigap insurer,, or any information needed to determine these benefits payable for related services. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original. I am responsible for any co-pays, co-insurance, deductible or non-covered services. Patient Signature

12 BVA Cash Payment Policy & General Insurance Payment Policy The goal of BVA Advanced Eye Care is to provide out patients with exceptional care. For us to maintain this high standard of care, we respectfully request all co-pays, coinsurances, or deductibles which apply be paid at the time services are rendered. Your appointment today may be for an initial consultation; however, the doctor may find it medically necessary to perform additional testing. If you have questions regarding cost, etc. for any additional tests, please ask any of our staff as you or your insurance company will be charged for services rendered. If your insurance company does not pay or denies your claim within 60 days, you are responsible for payment. We will be glad to assist you in determining any benefit information or acquiring any other information needed from your insurance company. Payment is expected when services are rendered, unless other arrangements are made in advanced. If you have any questions, please feel free to ask for assistance. Note: We will be glad to file any insurance on your behalf; however, we do not participate with all insurance companies. If you have an insurance plan that has preferred providers, you should first check to see if the doctor you are seeing is a member in your preferred provider organization. If you are not sure, please consult with our staff and we will verify this for you. If your insurance company does not cover a service or portion of our fees, you are responsible for this amount. As the policy holder, it is ultimately your responsibility to know your plan benefits, requirements, exclusions, and limitations. Our staff is available to assist you. Authorization: I hereby authorize BVA Advanced Eye Care to release all medical information necessary for processing of insurance claims to all insurers or their agents. I also authorize BVA to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning my health plan benefits and payments. I direct the insurance company or health plan administrator to release this information to BVA and allow a Xerographic copy of my signature to be used. I understand that these provisions will remain in full effect until otherwise revoked by me. State law requires that we advise you that the information authorized for release may include records which may indicate the presence of communicable or venereal diseases which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also know as Acquired Immune Deficiency Syndrome (AIDS). I certify that I have read and understand the above and have had each item explained to my satisfaction. Patient s Signature If I am not the patient, but instead signing on behalf of the patient, I further certify that I am legally authorized to sign on the patient s behalf and to bind the patient to the above terms and conditions. I agree that the patient and I are jointly and severally responsible for complying with the above terms and conditions, including any and all payment obligations. Representative s Signature Relationship of Representative to Patient