City. _Group#: Name of Policy Holder:. .Policy #: Cit. City. Citv: City; State; Zip: Address:

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1 7 Lttnw Thank you for choosing our practice for your eyecare needs. Please complete all forms in ink. If you have any concerns do not hesitate to ask for assistance, we will be happy to help you. If vou are new to our practice, please share with us your primary reason for choosing Lowcountry Vision Care: Our LCVC Savings Plan Location/convenience Yellow pages ad: Verizon HTC Other Ad or Letter (specify) Personal Referral: (name) Optical shop on site Insurance Participation PATIENT INFORMATION NAME: DOB / / SEX: M / F FIRST MIDDLE LAST SOC.SECURITY #: - - ARE YOU A MINOR SINGLE MARRIED DIVORCED STUDENT OTHER_ MAILING ADDRESS:_ CITY SIAIE ZIP. STREET ADDRESS: CITY STATE ZIP HOME PHONE: WORK PH; ELL_PJ± Preferred contact n EMERGENCY CONTACT: RELATIONSHIP: PHONE #: Occupation: Employer Name: Work Phone: (Ext) Employer Address, Citv: State Zir Address: PLEASE LIST NAME(S) & AGE(S) OF DEPENDENT CHILDREN IF PATIENT IS A MINOR CHILD, NAME(S) OF LEGAL GUARDIAN(S): Responsible Party Name of person responsible for this account:..relationship: Address: City. Slate. Phone#:.Employer:. City. State: Insurance Information Primary Insurance Co.\.Policy #:.ZlJL. _Group#: Name of Policy Holder:..Relationship to patient: Insured's DOB: l Soc. Security #_ Home phone: Street Address: Mailing Address: Cit City. State; State; Zip; Zip; Secondary Insurance Co: Policy #; Group#: Name of Insured:..Relationship to patient: Insured's DOB: Soc. Security # Home phone: Street Address: Citv: State; Zip: Mailing Address:. City; State; Zip: Employer Name:. Address: / certify that the insurance information on this form is accurate. I understand J am financially responsible for copays, deductibles & non-covered services by my insurance company(s) I understand that you may bill me if my insurance company takes longer than 90 days to make it's payment decision. If my insurance company does subsequently pay you, you will refund to me any portion that is due to me If my insurance company denies payment, I agree to be personally responsible for payment. I authorize the doctor to release any information necessary to secure payment of benefits and use of this signature for all insurance claims unless revoked in writing. Signature Dote / /

2 Current Visual Function: If you are here due to a vision or eye health problem, please describe your concerns or symptoms: Do you currently wear: Glasses Contacts Both Sunglasses Safety Frames 1f you wear prescription glasses or contacts, when are they used?: All the time Distance only Reading/near work only Safety/sports only Other I f you do not wear contact lenses, are you interested in learning if they would be right for you? Yes No What is your daily computer use? None Less than 1 Hr 1-3 Hours Over 3 Hours How much time do you spend reading/studying daily? None Less than 1 Hr 1-3 Hours Over 3 Hours How much time is spent crafting/close work daily? None Less than 1 Hr 1-3 Hours Over 3 Hours Please mark the following sports/recreations you participate in: Golf Basketball Hunting Boating/Sailing Swimming Tennis Softball Fishing Water/snow Skiing Scuba/snorkeling Walking Soccer Target Shooting Distance Running Other: Please list your hobbies or interests: Contact Lens Information.-Please indicate the type of contact lenses currently used, check all that apply: Soft Lenses Gas/Hard Lenses Toric Lenses(astigmatism) Bifocal Lenses Monovision Daily Wear lenses Extended Wear Colored Fashion Lenses Brand worn if known: Do you have any complaints with your current lenses? Do you experience Dry eyes? Are your lenses uncomfortable at times? If yes, When? How often do you remove your contacts? Replace them? General Eye 4 Health History Please rate your current overall physical health: Excellent Good Average Poor Name & address of Physician: Office Phone:( ) Date last seen, Previous eye doctors name & address: Office Phone:( ) Date last seen:

3 General Health jjjjtjgg continued Please mark in the appropriate column if you currently have (Q or previously have hadjplany of the followin&conditions. In column (F) if a blood family member has or had the condition, please write in their relationship to you; ie mother, brother, etc. A thorough health history contributes to a thorough and comprehensive examination. Condition C P F Coadsaoa C P P aids/hiv + allergies amblyopia(lazy eye) i * asthma arthritis blurring burning color blindness k cataracts cataract surgery cancer cardiovascular disease k diplopia( double vision) dryness diabetes - T diabetic retinopathy K ear,nose,throat infections eye infection 1 eye injury epilepsy emphysema eye surface hemorrhage eye surgery eyelid infections (stye) eyelid surgery(eye lift) fainting disorder i glaucoma K head injury/trauma j high cholesterol/lipids * high blood pressure a j itching iritis/uvie tis I kidney disease * light sensitivity I liver disease lupus macular degeneration r migninea/chromc headaches 1 ptosis(one drooping eyelid) pain redness retinal detachment strabismus(crossed eyes) r soreness [strain ' sinus infections stroke thyroid disease vision flashes vision Toss swelling shingles tearing vertigo(dizzy spells) vision floaters Other: - - t w itiave cornpletedtks history form to the best of my knowledge. Signed : Date: / /

4 Lowcountry Vision Care's Financial Pnlirv It is the patient's responsibility to provide Lowcountry Vision Care with any current insurance, address and/or referral information and forms. The patient must pay all co-payments, co-insurances and non-covered services at the time of their appointment. If a determination of benefits cannot be established by the time of your visit, you are expected to pay in full for services rendered. We will reimburse to you any payment, subsequent to that date of service, your insurance company remits to our office. If eyewear or contact lenses are ordered, a deposit of 50% is required.we place orders the same day, any order cancellation is subject to a 25% restocking fee The balance is due in full upon day of dispense unless other arrangements have been made in advance. Goods not picked up within 180 days will be considered abandoned & donated to the Lions Club with the deposit forfeit. If your insurance company requires you to obtain a referral to see a specialist, you must present it on the date and time of your appointment(or earlier). If your claim is denied because a referral was required and none was obtained or if you fail to reply to a coordination of benefits request by your insurance company, you'll be responsible for all charges incurred for that date(s) of service. If your insurance carrier has not reached a decision within 90 days of billing, payment will be due in full from the patient.by signing this financial agreement, the patient authorizes Lowcountry Vision Care to furnish information to insurance carriers and other doctors concerning his/her treatment.they may also obtain pre-certifications and prior authorizations on the patient's behalf. Lowcountry Vision Care is authorized to receive payments for services rendered on behalf of the patient and/or their dependents.this authorization remains on file for all future treatments unless revoked by the patient in writing. NOTICE OF PRIVACY PRACTICE You may review or ask to receive a paper copy of the complete Notice of Privacy Practices at any time. You may make the request over the phone or in person at the reception desk. The Health Insurance Portability & Accountability Act of 1996(HIPAA) is a federal program that requires that all medical records & other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand & control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information & how we may use & disclose your information. We may use and disclose your medical record only for any of the following purposes: *Treatment-providing, coordinating or managing health care & related services by one or more health care providers. Examples would be providing refraction prescription and/or eye health conditions when patient referral to a specialist is required, when prescription spectacle or contact lenses are ordered, and when an eye health medicine is prepared for a pharmacist. *lnsurance Claims- providing information to an insurance company in order to request payment for services and/or treatments rendered and for durable goods. We may contact you to provide appointment reminders, test results, information about treatment options or other eyecare benefits & services that may be of interest to you. This contact may be made via any of the phone numbers or addresses you provide to us. Disclosure of your medical information for the above stated purpose might be made orally, via fax, or by mail as we may conside most effective for providing your eyecare.any other uses & disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.you have the following rights with respect to your protected health information, which you can exercise by presenting a written request to Lowcountry Vision Care. *The right to request a restriction on certain uses & disclosures of protected health information, including disclosures to family members, other relatives, close personal friends or any other person identified by you. *The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. *The right to inspect & copy your protected health information. *The right to receive an accounting of disclosures of protected health information Your signature below indicates your acceptance of the terms of the above HIPAA policy and Financial policy. Signature Pate: / Print Name PQB / / /

5 Name: Phone Lowcountry Vision Care Universal Medication Form Signature I have no medication allergies Birth date: Allergic to /describe reaction Allergic to / describe reaction List all prescription medications including eye drops & over the counter (non-prescription) Medications, vitamins & herbal supplements-examples: Ginseng, St Johns Wort, aspirin, Tylenol Todays Date Medicine/dosage Time taken Date Stopped Reason for taking and Prescribing doctors name