PATIENT INFORMATION NAME (Last, First Middle) MRN SSN# BIRTHDATE LANGUAGE SEX

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1 PATIENT INFORMATION NAME (Last, First Middle) MRN SSN# BIRTHDATE LANGUAGE SEX LOCAL ADDRESS REFERRING PHYSICIAN SECONDARY/BILLING ADDRESS ETHNICITY HOME PHONE DAY PHONE ADDRESS PRIMARY CARE PROVIDER RACE MARITAL STATUS PRIMARY EMPLOYER STUDENT STATUS SMOKER (Y/N)? VETERAN (Y/N)? EMERGENCY CONTACT NAME CONTACT PHONE HOME PHONE Full-Time Part-Time SECONDARY EMPLOYER (if Applicable) ADDRESS ADDRESS WORK PHONE WORK PHONE RESPONSIBLE PARTY INFORMATION (if Different than above) NAME (Last, First Middle) SSN# BIRTHDATE LANGUAGE SEX LOCAL ADDRESS SECONDARY/BILLING ADDRESS (if Applicable) HOME PHONE DAY PHONE ADDRESS MARITAL STATUS STUDENT STATUS SMOKER (Y/N)? VETERAN (Y/N)? PRIMARY CARE PROVIDER Full-time Part-time HOME PHONE RELATIONSHIP TO PATIENT PRIMARY INSURANCE NAME OF INSURANCE COMPANY POLICY# NAME OF INSURED GROUP# ADDRESS OF INSURANCE COMPANY COPAY AMT PHONE DEDUCTIBLE RELATIONSHIP TO PATIENT EFFECTIVE DATE EXPIRATION DATE SECONDARY INSURANCE (if Applicable) NAME OF INSURANCE COMPANY POLICY# NAME OF INSURED SSN# BIRTHDATE GROUP# ADDRESS OF INSURANCE COMPANY COPAY AMT PHONE DEDUCTIBLE RELATIONSHIP TO PATIENT EFFECTIVE DATE EXPIRATION DATE I DO / DO NOT (circle one) have a Healthcare Power of Attorney FOR INTERNAL USE ONLY: POA Document Provided Yes / No Preferred Contact Method (circle): Phone Call / No Automated Call / No Preference The Affordable Care Act requires SEC to collect some sensitive information, such as: Race/Lang/Ethnicity. You have the right to DECLINE to answer any or all of these questions. SIGNATURE OF PATIENT/GUARDIAN DATE

2 HEALTH HISTORY QUESTIONNAIRE Name Date of Birth ID #: Date List any medications you currently take (Rx and/or over the counter): Date of last eye exam Do you have any allergies to any medications or substances, including Latex? (Circle one): YES NO If YES, list the medications or substances and your reaction: List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.): List any surgeries you have had (cataract, appendectomy, etc.) and the year(s) they were performed: Do you currently have any problems in the following areas? If YES, please provide additional information. YES NO Additional Information EYES (Poor vision, eye pain, tearing, redness) GENERAL / CONSTITUTIONAL (Fever, heat stroke, weight loss or gain, fatigue) EAR / NOSE / THROAT (Hard of hearing, stuffy nose, earache, cough, dry mouth, etc.) CARDIOVASCULAR (High BP, racing pulse, etc.) RESPIRATORY (Congestion, wheezing, shortness of breath, etc.) GASTROINTESTINAL (Stomach upset, diarrhea, constipation, hernia, ulcers, etc.) GENITAL, KIDNEY, BLADDER (Painful or frequent urination, impotence, jaundice, prostate) FEMALES (Are you pregnant? Nursing?) MUSCLE, BONES, JOINTS (Joint pain, stiffness, swelling, cramps, arthritis, etc.) SKIN (Pimples, warts, growths, rash, eczema, etc.) NEUROLOGICAL (Numbness, headache, seizures, paralysis, etc.) PSYCHIATRIC (Anxiety, depression, insomnia) ENDOCRINE (Diabetes, thyroid, etc.) BLOOD / LYMPH (Bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.) FAMILY HISTORY (Mother, Father, Grandparent, Sibling) Has any member of your family had these diseases? (Circle all that apply) YES NO UNKNOWN Blindness Cataract Glaucoma Diabetes Stroke Cancer Thyroid Disease Arthritis Other heritable disease: SOCIAL HISTORY Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)? YES NO Caffeine? YES NO Have you ever had a blood transfusion? YES NO Do you use recreational drugs? YES NO FORMERLY Do you drink alcohol? YES NO If YES, how much? How often? Do you use tobacco? YES NEVER FORMERLY If YES, what kind? How much? If FORMERLY, how long? When did you stop? Patient Signature Date Health History Questionnaire_jcollins

3 STATEMENT OF FINANCIAL RESPONSIBILITY WELCOME! Thank you for choosing Southwestern Eye Center as your vision care provider. We are committed to providing you with the best possible care. Your clear understanding of our practice financial policy is important to our professional relationship. We make every effort to keep our fees reasonable while at the same time covering the cost of services we provide. Payment of your bill is considered part of our overall treatment. In order to keep healthcare costs to an absolute minimum, we have adopted the following policies. Fees and Payments Fees are standard and based on the complexity of your visit. Payment in full is required at the time of your visit and can be made with cash, personal check, money order, Visa, MasterCard, or Discover. While, filing insurance claims is a courtesy that we extend to all of our patients, all charges are your responsibility from the date services are rendered. Southwestern Eye Center will file claims to insurances provided (primary & secondary) during registration. Your insurance is a contract between you and/or your employer, and the insurance company, we are not party to that contract. In order for us to file a claim on your behalf, you must present a CURRENT copy of your insurance card(s) at each visit and communicate any changes in your personal information. Not all services are a covered benefit in all policies, so it is very important that you understand the provisions of your individual policy. Insurance companies select certain services that they will not cover, therefore we can t guarantee payment of all claims by your insurance company. Some common examples of non-covered services are refractions. Rejection of your claim does not relieve you of your financial responsibility to Southwestern Eye Center. If you do not provide your insurance information 3 days prior to your visit you will be considered self-pay and will be responsible for payment in full at your visit. PLEASE NOTE: Each visit is documented in your medical record and a diagnosis is made by the provider. Diagnoses are made based on medical information, not based on coverage by insurance companies. To request a diagnosis change solely for the purpose of securing reimbursement from an insurance carrier is inappropriate and is considered insurance fraud. Required at Check-in: 1. Verify personal contact information 2. Present current copy of insurance card 3. Present current picture ID 4. Payment of any outstanding balance 5. Payment for today s visit Self-Pay In order to address the needs of our patients without insurance and patients with coverage limitations, we offer a reduced rate off of our usual and customary fees. This discount acknowledges the lower cost involved in billing and collections when a claim does not need to be submitted to a third party payer. In order to qualify, payment needs to be made IN FULL prior to or upon completion of your visit or procedure. Any remaining balance is not eligible for a discount. This discount applies to all medical services provided and is offered only at time of service. Co-Payments Your insurance company requires us to collect co-payments at the time of service. Waiver of co-payments may constitute fraud under state and federal law. If you do not have your co-payment, your appointment may be rescheduled. 1 P a g e Updated 06/22/15 SEC FORM-013 Statement of Financial Responsibility RCM/BR

4 STATEMENT OF FINANCIAL RESPONSIBILITY Delinquent Balance Appointment Patients with a delinquent balance are required to make payment in full for all services. A delinquent account is defined as a patient balance in excess of 120 days if the patient has not made any payments or sought assistance via financial hardship during this time. If such payment is not made, services may be refused. Medicare and Medicaid We gladly accept Medicare and Medicaid patients and will bill our services at the allowed rates. Medicare regulations require that you sign an Advanced Beneficiary Notice (ABN) at every visit where your procedure may not be covered. This form helps to explain which services Medicare may not cover and may be your responsibility. Annual Eye Exams Please verify that your insurance will cover vision exams before making your appointment. Some insurances are very strict as to where you may receive your vision exam. Family Medical Leave Act and Disability Paperwork If your employer requires Family Medical Leave Act (FMLA) or Disability paperwork to be completed by your provider, we offer the following options: 1. A form created by our practice that meets the needs of both the employer and patient. Patients may request this form be filled out at any time to clarify their current condition. The turnaround time for this form can be up to 15 (fifteen) business days and there is no charge to the patient for this service. 2. Forms received directly from you or your employer requiring additional information take considerable time for the staff to complete. We are happy to complete these forms for you; however there can be up to a 15 (fifteen) calendar day maximum turnaround and a charge of payable in advance. Medical Records All Southwestern Eye Center patients may request a copy of their medical records via our Patient Portal. This can be done at no charge to the patient and received electronically within 30 (thirty) business days. Miscellaneous Charges Returned Check Charge Non-sufficient funds (NSF) checks are subject to a fee (this is not included in any fees incurred by your financial institution). Collection Charge Accounts that are not paid within 90 days from the date of service may be sent to an external collection agency and reported to one or all national credit bureaus. In addition to your outstanding balance, a 33% surcharge may be added to cover our costs. In addition, you may be removed from the practice. Refunds Patient refunds are processed on the third Thursday of every month. Any accounts that have outstanding claims will not be eligible for refund. Each surgical case involving elective or premium services will be assessed on an individual basis. Facility Fees All Southwestern Eye Center facilities are contracted with the insurance plans accepted by our clinic locations. Our agreement with your insurance company allows us to charge a lower rate than a hospital which helps to keep your premium rates lower. 2 P a g e Updated 06/24/15 SEC FORM-013 Statement of Financial Responsibility RCM/BR

5 RESPONSIBLE PARTY INITIAL THE FOLLOWING, AS RECORD OF FINANCIAL DISCLOSURE: 1. I understand that it is my responsibility to know my insurance benefits and plan coverage. My insurance may or may not cover the services provided at Southwestern Eye Center (SWEC). Please check with your insurance carrier, prior to your visit, to fully understand anticipated out of pocket costs. 2. I understand that SWEC will collect Estimated fees, at or prior to surgery and clinic visits, which include copayments, deductibles, coinsurance, unpaid balances and non-covered services. Cash, checks, MasterCard, Visa, Discover, and Debit Cards are accepted. Payment is due upon receipt of statement for balances not covered by my health plan. If my insurance pays me directly for services billed by SWEC it is my obligation to forward the payment to SWEC. 3.I understand that SWEC accepts both vision and medical plans. Vision plans cover routine eye exams and eyeglasses/contact lenses. All other billable services are usually sent to medical plans. 4. I understand that a refraction fee will be collected, following services, if I do not carry vision benefits and/or after surgery during the final post-operative visit if testing is necessary (only for patients receiving post op care at SWEC). 5. I request that payment of authorized medical benefits be made on my behalf to all related entities involved or participating in my eye care associated with SWEC. I authorize release of medical information necessary to my claim(s). 6. I understand that a 25 service fee will be added for any checks returned for any reason and I will be responsible for payment of this fee and the amount of the returned check. Non-sufficient fund checks must be redeemed with certified funds (cashier s check, money order or cash). 7. I understand the following No Show/Cancellation Policy: Clinic appointments canceled less than a 24 hour advance notice or failure to show up for an appointment will be charged a 25 fee for the first occurrence, 50 for two or more occurrences. If I arrive 30+ minutes late for an appointment, I may be rescheduled at the physician s discretion. Surgery appointments canceled less than a 48 hours advance notice or failure to show up for an appointment, without immediate rescheduling, will be charged a 100 fee. Oculoplastic Surgery appointments canceled less than a 17 day advance notice or failure to show up for an appointment, without immediately rescheduling, will be charged a 250 fee (functional appointment) or 15% of the charge estimate provided (cosmetic appointment). 8. I understand that I will receive an Advance Beneficiary Notice of Non-coverage (ABN), also known as a waiver of liability, for any service/treatment not covered by insurance. I agree to pay if my insurance rejects coverage. 9. I understand that my credit card information will be kept securely on file. It will automatically be charged for amounts not covered by insurance for services, outstanding balances, deductibles, copayments and arrangements established between myself and the SWEC billing department. 10. I understand that there may be fees associated with medical records requests and completion of forms by a physician. I understand that I may be responsible for paying these fees. 11. I understand that if my account has a patient responsibility amount that is not paid within 90 days then my account will be placed with an outside collection agency. No additional appointments will be made for delinquent accounts until they are brought current unless the appointment is of an urgent nature. 12. SWEC will charge a fee of 50 for the completion of forms/paperwork which is due at the time of the request. Forms received directly from you or your employer takes considerable time to complete. The turnaround for completion can take up to fifteen days. STATEMENT OF FINANCIAL RESPONSIBILITY: I acknowledge that I am responsible for all charges for all services provided, including any amount not paid by my health care plan(s). This also applies if I am covered by Medicare, a health maintenance organization (HMO), or any other payer. I have read and understand the above Financial Policy and I agree to abide by its terms. Printed Name of Patient: ID: Signature of Patient/ Responsible Party: Date:

6 PATIENT ACKNOWLEDGEMENT PATIENT NAME: ID: Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this acknowledgement. By signing this form, you acknowledge that you had the opportunity to review the Southwestern Eye Center Notice of Privacy Practices describing the use and disclosure of protected health information about you for treatment, payment, health care operations, and other uses and disclosures as stated in our Notice. We provide this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. Protected health information includes, but is not limited to, information related to psychologic disorders, sickle cell anemia, HIV / AIDS, communicable disease, and alcohol and drug abuse diagnosis and treatment, if such information exists. Southwestern Eye Center has a Notice of Privacy Practices and that the patient has the opportunity to review the Notice. Southwestern Eye Center reserves the right to change the Notice of Privacy Practices at any time. A current copy of the Notice may be obtained by contacting our office, or at The patient may revoke this Consent in writing at any time and all future disclosure will then cease. AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION UPON REQUEST I,, give my permission to disclose protected health information from my health records, including financial information, to the following person(s): Name(s): Signature: Date: AUTHORIZATION TO ASSIGN BENEFITS AND STATEMENT OF FINANCIAL RESPONSIBILITY I authorize and request that the payment of Medicare and/or insurance benefits be made directly to Southwestern Eye Center for any and all services provided to me by Southwestern Eye Center. If my health insurance will not allow direct payment to Southwestern Eye Center or if Southwestern Eye Center chooses not to accept assignment of medical benefits, I agree to immediately forward to Southwestern Eye Center any and all health insurance payments I receive. I acknowledge that I am responsible for all charges for services provided by Southwestern Eye Center, including any non-covered services or amounts not paid by insurance. This also applies if coverage is provided by Medicare, a Health Maintenance Organization, a Worker's Compensation policy, or any other third-party payers. Printed Name: Signature: Date: Relationship to patient (if other than patient): GENERAL CONSENT TO TREATMENT By signing below, I authorize the health care providers at Southwestern Eye Center, to conduct examinations, diagnostic tests and procedures to assess my health care conditions, and to provide care, services or therapies necessary to effectively diagnose and treat me. I understand that it is the responsibility of my treating health care provider(s) to explain to me the nature of proposed care, treatment, services, prescribed medications, suggested interventions, or procedures. Before I undergo particular procedures or tests, my provider(s) will explain the potential benefits, risks, or side effects, including potential problems that might occur during recuperation, the likelihood of achieving goals, reasonable alternatives, and the relevant risks, benefits, and side effects related to alternatives, including the possible results of not choosing to undergo the recommended treatment. I consent to the presence of students, trainees, observers, medical sales representatives, and/or non-facility personnel as deemed necessary and/or appropriate at the discretion of my physician and/or the management of Southwestern Eye Center. Printed Name: Signature: Date: Relationship to patient (if other than patient):

7 PRE-AUTHORIZED HEALTH CARE PAYMENT I authorize Southwestern Eye Center to keep my signature on file and to charge my: Visa MasterCard Discover Balance of charges not paid by my insurance within 90 days not to exceed per month or a total of for the year for services rendered: this visit only (visit date) all visits this year Recurring charges (on-going treatments, extended payment arrangements) of per month until the balance is paid in full. Every from to. (Frequency) (Beginning date) (Ending date) I assign my insurance benefits to Southwestern Eye Center. And I further understand that this form is valid for one year unless I cancel the authorization through written notice to the office location where services were rendered. PATIENT NAME CARD HOLDER NAME CITY STATE ZIP CARD HOLDER SIGNATURE DATE FOR OFFICIAL USE ONLY MR# DOB Y:\RCM - Workflow, SOP's and Training Material\10. Forms\SEC\SEC FORM-003-FO-Pre Authorized Healthcare Payment.docx RCM/KL