Eugene Eye Clinic, LLC

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John D. Polansky, M.D. & Jason P. Gross, M.D. 2460 Willamette Street, Eugene, OR 97405 Phone (541) 683-3744 Fax (541) 683-6672 www.eugeneeyedoctors.com Welcome to the Eugene Eye Clinic is scheduled for an appointment on with Dr. Polansky / Dr. Gross. Please arrive at to check in. The office is located on the corner of 24 th Place and Willamette Street. Patients may park in our private lot on either side of the building. The office suite is located on the lower level and can be accessed via the stairs or ramp. Please complete all the included forms and bring with you to your appointment to help expedite the registration process. Please remember to bring your insurance cards and photo identification. By providing your correct insurance information, your benefits can be verified and billed correctly. Please refer to the enclosed Medical vs. Vision Waiver for explanation of different exam options. Your eyes may or may not be dilated, depending on your specific needs. Most patients are able to drive themselves after dilation, while others may need a driver to accompany them. Please allow 1½ - 2 hours for your initial exam. Bring your most recent pair of eyeglasses and a list of your current medications. If you wear contact lenses, wear them to your appointment. Your lenses must be worn for at least 2 hours prior to your appointment. Please bring your contact lens RX information, i.e. written RX or packaging. Co-payments and fees for non-covered services are collected at time of check-in. Our office accepts cash, check and Visa/American Express/MasterCard/Discover. The Spectacle Shop is conveniently located in our office for your eyewear needs. The Spectacle Shop is open Mon.-Fri. 9:00-1:00 and 2:00-5:00. Their telephone number is (541) 683-3746.

EUGENE EYE CLINIC, LLC JOHN D. POLANSKY MD AND JASON P. GROSS MD MEDICAL VS. VISION BENEFITS WAIVER WHY DO I NEED TO CHOOSE BETWEEN A MEDICAL EYE EXAM AND A VISION EYE EXAM? There is significant confusion regarding insurance coverage for eye exams. Some vision plans only cover Routine vision exams while others will cover your exam only if you have a medical eye condition or disease. Our staff will ask whether you are here for a medical eye exam or a Routine vision exam. We can do our best to educate you on your benefits, but we do not want to choose your exam for you. Also, we cannot re-file your claim with a different benefit once the initial claim has been filed. VISION EXAM A Routine Vision exam is for people who do not have medical eye disease(s) or symptoms of disease. Your eyes will be examined for any needed correction (glasses or contacts) or any potential indicators of eye disease. A Routine vision exam allows you to update your glasses and/or contact lens prescription and screen the health of your eyes. For this type of visit, vision insurance is billed. If our doctors find anything medical during your vision exam, the discussion and possible further testing may be needed at an additional visit to address the medical findings. In that case, your medical insurance would be billed for that next visit. If you are concerned about medical conditions, you should choose to bill your medical insurance. MEDICAL EXAM A comprehensive Medical eye exam is for the diagnosis and treatment of disease(s) and/or condition(s) of the eye performed by a physician. This exam evaluates the reason for the symptoms and assesses any treatment needed. Some conditions evaluated with a medical exam include dry eyes, allergies, red eyes, cataracts, glaucoma, diabetic retinopathy, macular degeneration and other sight-threatening diseases. In most cases your eyes will be dilated so the doctor can get a good view of the inside and back of your eye. For this type of visit, medical insurance is billed. WHAT IF I HAVE BOTH MEDICAL AND VISION INSURANCE? Some insurance plans allow us to bill both types of insurance to utilize your benefits in the way that best suits your situation. If you have medical problems related to your eyes, you should use your medical benefits. However, if you need your prescription, then the refraction portion of your exam may be billed to your vision benefit by checking both Medical & Vision options listed below. Most patients will have a refraction done during either type of exam. A refraction is a diagnostic test used to determine your best corrected vision. For some medical conditions, a refraction is needed even when eyeglasses aren t prescribed. The majority of insurance company s do not cover this procedure. If your insurance doesn t cover your refraction you will be asked to pay the fee of $50. Please Bill Today s Visit to My Medical Insurance Vision Insurance Patient Signature: Date:

2460 Willamette Street Eugene, OR 97405 (541) 683-3744 Fax (541) 683-6672 John D. Polansky, M.D. The Spectacle Shop Jason P. Gross, M.D. (541) 683-3746 To Our Valued Contact Lens Wearers, Dr. Polansky, and Dr. Gross desire is to exceed the standards set for safe and healthy contact lens wear. For our patients an Annual Contact Lens Evaluation is needed to meet these standards. A prescription for contact lenses is good for 12 months from your last exam. An Annual Contact Lens Evaluation is needed to continue to prescribe contact lenses. The fee for this service is $75. Should a change in contact lens material be warranted, additional fee will apply. This evaluation will be performed at your complete vision exam and is a separate charge from the exam itself. If you are only in need of a new contact lens prescription an Annual Contact Lens Evaluation will need to be done in order to renew your contact lens prescription. All contact lens services are to be paid for at the time of service. All contact lenses and contact lens services are charged through The Spectacle Shop. Please call your insurance carrier directly if you have questions about coverage for contact lenses and contact lens services. If you have questions regarding charges for contact lens services please call The Spectacle Shop at (541) 683-3746, Monday through Friday 9 a.m. - 5 p.m. Thank you for continuing to trust us with your vision needs. Sincerely, Dr. Polansky, Dr. Gross, and Staff

PATIENT REGISTRATION FORM Eugene Eye Clinic, LLC Jason P. Gross, M.D. 2460 Willamette Street John D. Polansky, M.D. Eugene, OR 97405 PATIENT INFORMATION Today s Date: Name: (Last) (First) (MI) Address: City: St.: Zip: Email Address: Social Security No.: Date of Birth: Preferred Method of Contact: Phone Call / Text / Email Home phone no.: Cell phone no.: Work phone no.: Sex: M / F Marital Status: S / M / D / W / DP Patient Employer: Emergency Contact Person: Relationship: Home#: Cell#: Work#: How did you hear about our office? Who is your Primary Care Physician? INSURANCE INFORMATION Primary Insurance Co: Subscriber name: Relation to patient: Subscriber s DOB: Secondary Insurance Co: Subscriber name: Relation to patient: Subscriber s DOB: Legal Guardian or Power of Attorney Information Name: Relationship: Date of Birth: Phone #: Signature:

MEDICAL HISTORY QUESTIONNAIRE Name: Today s Date: Date of Birth: Date of last eye exam: Primary Care Physician: Your Occupation: List any medications you currently take, prescription AND over the counter: Do you have any allergies to any medications? YES / NO If YES, list the medications: List all major illnesses (glaucoma, diabetes, high blood pressure, heart disease, asthma, etc.) or injuries (concussions, etc): List any EYE surgeries you have had: Are you CURRENTLY experiencing any of the following? Please circle all that apply. CARDIOVASCULAR: High blood pressure/heart disease/other: RESPIRATORY: Congestion/Wheezing/Asthma/Other: GENITAL, KIDNEY, BLADDER: Painful urination/frequent urination/other: ENDOCRINE: Diabetes/Hyperthyroid/Other: NEUROLOGICAL: Numbness/Headaches/Seizures/Paralysis/Other: MUSCLES, BONES, JOINTS: Joint pain/stiffness/cramps/swelling/arthritis/other: GASTROINTESTINAL : Stomach upset/diarrhea/ulcers/constipation/hernia/other: CONSTITUTIONAL: Fever/Heat stroke/weight loss/weight gain/unusually tired/other: EYES: Poor vision/eye pain/tearing/redness/other: EARS, NOSE, THROAT: Hard of hearing/earache/stuffy nose/cough/dry mouth/other: BLOOD / LYMPH: Bleeding/Anemia/Other: ALLERGIC / IMMUNOLOGIC: Sneezing/Swelling/Redness/Itching/Hives/Lupus/Other: SKIN: Pimples/Warts/Growths/Rash/Other: PSYCHIATRIC: Anxiety/Depression/Insomnia/Other: FEMALES: Are you pregnant? Y / N Are you nursing? Y / N Family History Has any immediate family member had any of the following? If yes, please list whom. Cataracts: Y/N Macular Degeneration: Y/N Glaucoma: Y/N Diabetes: Y/N Other Eye Diseases: Y/N Other hereditary disease: Y/N Social History Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)? YES / NO Have you ever had a blood transfusion? YES / NO If Yes, Date of transfusion: Do you drink alcohol? YES / NO If YES, how much? How Often? Do you use tobacco? YES / NO If YES, how much? How many years? Do you use recreational drugs? YES / NO If YES, Please explain: Jason P. Gross, M.D. / John D. Polansky, M.D. Date

John D. Polansky, MD Jason P. Gross, MD 2460 Willamette Street Eugene, Oregon 97405 541-683-3744 Authorization to Discuss Health Information with Friends, Family or Caregivers Patient name Patient DOB I authorize Eugene Eye Clinic, LLC to leave a personal voice message or recorded message on the primary phone number I have provided. Please initial: I do not authorize Eugene Eye Clinic, LLC to discuss my information with anyone other than myself. OR I authorize Eugene Eye Clinic, LLC to discuss the areas I have identified below with the individuals listed. Unlimited access to all information listed below Insurance and Billing information Discuss treatment and diagnosis Please print: Name of authorized person Relationship Phone Number Name of authorized person Relationship Phone Number Name of authorized person Relationship Phone Number Patient Signature Date This authorization will remain in effect until revoked or updated by the patient.

John D. Polansky M.D. Jason P. Gross M.D. 2460 Willamette Street Eugene OR, 97405 FINANCIAL AGREEMENT Welcome to Eugene Eye Clinic, LLC. We would like to inform you about our office s financial and privacy policies. FOR ALL PATIENTS: By signing below, I acknowledge that I have provided my current insurance information and I authorize the release of any medical information necessary to process claims. I authorize payment of medical benefits directly to Eugene Eye Clinic, LLC for services performed by John D. Polansky, MD, or Jason P. Gross, MD. I acknowledge that Eugene Eye Clinic, LLC will bill my insurance as a courtesy. Any services not covered by my insurance will be my responsibility, including services denied due to lack of referral from my primary care provider. Any balances due are to be paid within 90 days of the statement date. After 90 days any balance due will be turned over to an outside collection agency. While payment in full is preferred, you may discuss payment arrangements with the billing staff. I also request payment of government benefits on my behalf to Eugene Eye Clinic, LLC. Date: Signature: FOR MEDICARE PATIENTS: I request that payment of authorized Medicare benefits be made on my behalf to Eugene Eye Clinic, LLC for services furnished me by John D. Polansky, M.D, or Jason P. Gross, M.D. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Eugene Eye Clinic, LLC accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non covered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier. Date: Signature: HIPAA Privacy Acknowledgment We are required by law to protect the privacy of your medical information and to provide you with our written Notice of Privacy Practices. Our Notice of Privacy Practices is available for you to review at your convenience in our waiting areas and front desk. Please take a copy for your records. By signing below, you acknowledge that you have received a copy of our Notice of Privacy Practices. Your patience and cooperation is greatly appreciated. Date: Signature:

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