Morgan Vision Care Patient Information

Name

Deemed Consent

Under Virginia law, if any employee or agent of the practice is exposed to your blood or other bodily fluids in a manner which may transmit human immunodeficiency virus (HIV) or hepatitis B or C viruses, you shall be deemed to have consented to testing for infection with HIV or hepatitis B or C viruses. In addition, you shall be deemed to have consented to the release of such test results to the person who was exposed.

Assignment of Benefits, Release of Information and Financial Agreement

I hereby authorize my insurance company (Medicare, Medicaid, Tricare, Anthem, Optima, etc.) to reimburse my Morgan Vision Care, PC physician directly, realizing that I am responsible to pay non-covered services at the time of service and I hereby authorize the release of pertinent medical and/or billing information to my insurance carrier for billing purposes only. I hereby authorize treatment by Morgan Vision Care, PC as deemed necessary by the provider. I accept responsibility for payment of all treatment that the payor determines does not constitute covered services as well as attorney's fees and any other related costs of collection should such action become necessary.

Signature on File

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductibles are based upon the charge determination of the Medicare carrier.

Morgan Vision Care Financial Agreement and Release of Information

Thank you for choosing Morgan Vision Care, PC for your vision care needs. We are committed to excellence in serving your vision care needs and providing satisfactory eye health treatment. Please understand that payment of your bill is considered a part of your treatment.

Self-pay or non-covered services are due in full at the time services are rendered. We accept CASH, CHECKS, VISA, MASTERCARD, DISCOVER and CARE CREDIT.

Insurance

As a courtesy to our patients. Morgan Vision Care, PC will verify your benefits and eligibility as well as file your insurance claims for you. This includes Medicare, Medicaid, Tricare (Champus), Anthem and Optima, as well as any commercial plans we participate with. If you choose not to have us file your claim for you, then you accept full financial responsibility at the time services are rendered. Please remember that your insurance is a contract between you and your insurance company. You are ultimately responsible for knowing your benefits and eligibility for services rendered prior to receiving them. All co-pays and deductibles are due at the time of service. It is the patient's responsibility to update us when there are any insurance changes, failure to do so will result in the patient being billed for 100% of the service charge.

There will be a $50.00 fee for all returned checks.

Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. Generally, you will be responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Financial Policy

Statements are mailed out on a monthly basis. You will receive a bill from us whenever your insurance company pay on a charge and leaves a balance due which is your responsibility. We ask that bills be paid within 30 days, unless prior payment arrangements have been made with our billing personnel. If you are unable to pay your balance within 30 days, we ask that you contact our billing personnel to make necessary arrangements.

If for any reason, you do not receive a statement, it is your responsibility to contact our office to ensure that your account has been satisfied by your insurance company. In the event that you move or have a change of address, it is your responsibility to inform us of your new address. Statements returned to us by mail will be forwarded to collections if no forwarding address can be obtained. There will be a 1.5% monthly service charge on unpaid balances over 30 days old. If the account is not satisfied within 90 days, it will be forwarded to a collection agency. The patient will be responsible for any collection/attorney/court fees, if applicable, associated with collecting the physician's fee.

Record Retention

Morgan Vision Care, PC maintains an electronic health record of all patient treatments, demographic and billing information. Please be assured your records are kept secured in our electronic system and can only be accessed by our Morgan Vision Care, PC staff for purposes of your treatment. Our office maintains patient records for at least 5 years from the last patient encounter. After that time, our office may destroy your records in a manner which protects patient confidentiality.

I hereby attest that I have read the above information in its entirety and completely understand its context and acknowledge by my signature below that I agree to the terms and conditions set forth above.

Privacy Statement

The Privacy Act of 1977 was established to protect your privacy and to give you security in knowing that when you come to our office, your medical and financial affairs will not be disclosed with anyone without your permission. This includes your spouse and/or family member(s).

It is a felony for our staff to give out this information without your written consent. Please take a moment and list anyone whom you would like to give us permission to discuss your personal health information with.

Emailing Prescriptions and Medical Records

Duty to Warn

Health and Human Services states that covered entities are permitted to send individual unencrypted e-mails if they have advised the individual of the risks associated with unencrypted e-mail. If the patient wishes to receive emails, Morgan Vision Care is expected to notify the individual that there may be some level of risk that the information in the e-mail could be read by a third party. We can email exam summaries, contact and glasses prescriptions, and receipts.

Digital Retinal Photographic Examination

Morgan Vision Care is proud to offer our patients a state of the art image of the inner eye, which provides a more thorough eye exam. Using our highly advanced Digital Retinal Photography, we are able to screen for eye diseases within the retina, which dramatically improves our ability to evaluate your retinal health.

Some of the diseases we will be screening for include, but are not limited to: retinal detachments, glaucoma, macular degeneration, retinal holes, as well as diabetic retinopathy (all of which may lead to partial loss of vision and/or blindness). In addition, systemic diseases such as diabetes and the effects of high blood pressure may also be detected during this exam. However, if you have already been diagnosed with diabetes, you are required to be dilated at least once a year. Therefore, if this is your first visit for the year, we will plan to dilate you today and you are welcome to return within the year to receive the digital retinal photographic examination.

Early Detection of Eye Disease is Crucial

An annual Digital Retinal Photograph is recommended in order to evaluate your retina at up to 100 times its normal size. You can expect the following from this exam:

• In depth view of the retinal surface (where diseases first manifest themselves)

• Evaluation and explanation of your retinal images from Dr. Morgan

• Permanent record for your medical file for serial analysis, comparisons, and diagnosis

• Fast, easy and comfortable

• Typically, no dilation drops are needed

Insurance is designed to cover a basic eye exam, therefore, it does not cover this procedure. The additional fee is S39.00.