Insurance Plans Accepted at Thomas Eye Group

Our offices participate in many major health insurance plans. Coverage varies with each patient and insurance company. It is the patient’s responsibility to know his or her benefits. Not all insurance companies will cover a non-medical office visit (for example, a routine eye exam each year including a refraction) and Thomas Eye Group does not accept every vision plan tied to the health insurance plan. Our staff will assist you in determining your eligibility prior to your appointment. Below is a list of our currently accepted health insurance plans:

• Aetna
• Beech Street Corporation
• BCBS of Georgia
• Cigna
• Coventry Healthcare
• Eyemed
• Humana Employer's Health
• Humana Vision
• Medicaid - SSI Peachcare
• Medicare Advantage Plans (do not accept Kaiser)
• Multiplan
• Railroad Medicare
• Tricare
• United Health Care
• USA Managed Care
• Vision Service Plan (VSP-Select Plans)

Please click on the appropriate link to complete your registration. When you submit this information it transmits directly and securely into our computer system and will be ready for you when you arrive for your appointment. If you are a new patient it would be best to print your completed forms at the end of the online registration just to be safe.

• Adults
• Pediatrics

New Patients -

Please print and complete if you do not plan to complete the online registration.

• Medical History - Adult
• Medical History - Pediatric
• Protected Health Information/ Authorization
Miscellaneous:
• Medical Records Release Form

OUR FEES AND OUR PAYMENT POLICIES

To our Patients:

We are here to provide you with the eye care you need. We have established fees and payment policies that enable us to have the quality staff and facilities that are necessary to provide the care you expect. This explanation of our payment policies has been prepared so that you can help us maintain quality services. Like you, we are very concerned about the cost of health care. Our payment policies are designed to enable us to reduce unnecessary collection costs which would otherwise increase the cost to our patients.

We know that insurance plans are confusing to almost everyone. However, by understanding your insurance or HMO plan’s requirements and our policies you will avoid surprises regarding your payment obligations. Our staff is available at each office to explain our policies.

Your Responsibilities For Charges

You are ultimately responsible for the payment of charges for services you receive. We rely on the accuracy of information you provide to determine if a third party will be responsible for payment. If you will be paying personally for services or if you are responsible for a deductible or co-payment, we expect payment at the time service is rendered. We accept cash, personal checks, VISA, MasterCard, Discover and American Express. For surgical services and charges from our Ambulatory Surgery Center, we also accept Care Credit. If you are experiencing personal circumstances that will make the payment of our charges difficult for you, please ask to speak with our business supervisor prior to your visit.

If payment is to be made through an insurance or medical plan and we have agreed to accept assignment from that plan, then you are responsible for complying with all procedures required by that plan to enable us to receive payment on your behalf. To assure that your insurance or medical plans will provide covered benefits, you must let us know at the time you schedule your appointment and when you check in, how you plan to provide payment for your visit.

You are responsible for payment of any non-covered services as well as finance charges for overdue payments and fees for returned checks and collection agencies.

Medical Vs. Vision Services

Insurance plans differentiate between"medical" and"vision" problems. Most medical insurance plans do not pay for "vision" services. Most vision plans do not pay for "medical" problems. While some medical problems are obvious, when you have an eye problem, it may be almost impossible for you to know if it is a "vision" or "medical" problem. If you have a medical eye problem we can file a claim with your medical plan. If you simply need an eye exam for glasses, that is usually a "vision” service and would not be covered by a “medical” plan but would be covered if you have a "vision" rider or a separate "vision" plan such as VSP or Eyemed.

When you make your appointment, please let us know what plans you have and we will help you determine which plans may be appropriate for your visit.

Medicare And Supplemental Plans

We accept assignment for Medicare and will file supplemental insurance claims for those plans that accept a claim directly from Medicare. If your supplemental plan does not accept a claim directly from Medicare, you must pay the co-payment to us and file a claim to your plan after you receive your EOB (Explanation of Benefits) from Medicare. A refraction, which is normally part of an eye examination, is NOT a covered service under Medicare and payment is your responsibility.

Insurance Plans

Your insurance company determines what they will or will not pay for. We rely on what an insurance company representative tells us to make an initial determination of coverage. Subsequent decisions made by your insurance company are outside of our control. We will generally file insurance for you for covered services. We do expect you to make prompt payment for any portion which the insurance company will not be responsible.

Referrals

We participate with many of the HMO and POS plans and other managed care medical plans currently offered in this area. If a written referral is required by your plan, you must provide such referral before the service is provided. If you do not have a valid referral form at the time of your visit, it will be necessary for you to pay for services at the time of the visit or to reschedule the visit.

Refraction Service And Fee

A refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of an eye examination and necessary to write a prescription for glasses or contact lenses. It is NOT a covered service by Medicare or most insurance plans. These plans consider a refraction a “vision” service not a “medical” service. Our office fee for a refraction is currently $66.00 and this fee is collected at the time of service in addition to any copayment your plan may require. However, if you pay at the time of service, we will allow you a prompt pay discount of $20.00. So your net cost would be $46.00. We will not file the charge for a refraction with an insurance plan unless we know that your plan pays for the refraction charge. Should your plan pay us for the refraction, we will reimburse you accordingly.

Contact Lens Evaluation and Fee

If you are having an eye examination and wear contact lenses, our professional staff will be evaluating your current contact lenses to determine the present appropriateness of your lenses. Our current fee for this service is $42.00 and is collected in addition to the fee for an eye examination.

Assignment And Medical Release Authorization

In order to request payment from any third party coverage we will ask you to authorize payment directly to Thomas Eye Group for services rendered to you. We will also request your authorization for any holder of medical or other necessary information about you to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, or to the billing agents of your insurance companies, or medical care plans, or to your employer for a Workers' Compensation claim, any information needed to determine benefits or make payments for a medical benefits claim.

Finance Charges And Return Check Fees

We appreciate that most of our patients are conscientious about timely payment. We regret the necessity of having to apply fees to collect delayed payments; however, these fees are necessary so that we do not pass on these costs to those who pay on a timely basis.

Thomas Eye Group will charge an 18% annual finance charge, 1.5% monthly, on all accounts with balances over 60 days that are patient responsible and any collection fees.

All returned checks will be subject to be re-deposited electronically without further notice and are subject to a processing fee of $25.00 or the state limit for any unpaid checks.

CareCredit Online Application

Other Questions

Our primary concern is that you receive the eye care you need. Your understanding of our fees and payment policies and your cooperation with our procedures will enable us to provide more satisfactory service to you. Should you have any questions regarding these matters, please speak with our business office staff at any location.

Please contact: michellm@thomaseye.com for more Information.

Effective Date: April 15, 2003

THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

If you have any questions about this notice, please contact: Privacy Officer, Thomas Eye Group, P.C., 5671 Peachtree Dunwoody Rd., Suite 400, Atlanta, GA 30342 (404) 256-1507

PURPOSE

This Notice of Privacy Practices ("Notice") describes how we may use and disclose your"Protected Health Information" to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. Protected Health Information is information about you that may identify you and that relates to your past, present or future physical or mental health or conditions and related health care services. This Notice also describes your rights in regard to your Protected Health Information, including your rights to access and control such information.

WHO WILL FOLLOW THIS NOTICE

This Notice describes Thomas Eye Group's practices and those of:

• All physicians, associates, and other Thomas Eye Group personnel.
• All departments and locations of the Thomas Eye Group, such as Pediatric EyeCare and Thomas Eyewear.
• All fellows, residents, medical students, and other trainees of, or affiliated with, Thomas Eye Group.
• All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share your Protected Health Information with each other for treatment, payment, or Thomas Eye Group operations for purposes as described in this notice.

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION

We understand that your Protected Health Information about you and your health is personal. We are committed to protecting your Protected Health Information about you. We create a record of the care and services you receive at the Thomas Eye Group. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by the Thomas Eye Group, whether made by Thomas Eye Group personnel or obtained from other doctors who may have treated you.

This notice will tell you about the ways in which we may use and disclose your"Protected Health Information". We also describe your rights and certain obligations we have regarding the use and disclosure of your Protected Health Information.

We are required by law to:

• Make sure that your Protected Health Information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to your Protected Health Information about you; and
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose your Protected Health Information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.

For Treatment. We may use your Protected Health Information about you to provide you with medical treatment or services. We may disclose your Protected Health Information about you to doctors, nurses, technicians, medical students, or other Thomas Eye Group personnel who are involved in taking care of you at the Thomas Eye Group. For example, your health information may be disclosed to a corrective lens provider to obtain appropriate glasses or contact lenses for you. We also may disclose your Protected Health Information about you to people outside the Thomas Eye Group who may be involved in your medical care, such as family members, a personal attendant, clergy, or others we use to provide services that are part of your care, such as therapists or physicians. We may use your Protected Health Information to notify you by telephone, mail or email of scheduled or recommended appointments for care.

For Payment. We may use and disclose your Protected Health Information about you so that the treatment and services you receive at the Thomas Eye Group may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received at the Thomas Eye Group so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Healthcare Operations. We may use and disclose your Protected Health Information about you for Thomas Eye Group operations. These uses and disclosures are necessary to run the Thomas Eye Group and make sure that all of our patients receive quality care. For example, we may use your Protected Health Information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine your Protected Health Information about many Thomas Eye Group patients to decide what additional services the Thomas Eye Group should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Thomas Eye Group personnel for review and learning purposes. We may also combine the Protected Health Information we have with your Protected Health Information from other medical practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of your Protected Health Information so others may use it to study health care and healthcare delivery without learning the identities of specific patients.

Treatment Alternatives. We may use and disclose your Protected Health Information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose your Protected Health Information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. We may release your Protected Health Information about you to a friend or family member who is involved in your medical care. This would include, but not be limited to, persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for your care. In addition, we may disclose your Protected Health Information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research. Under certain circumstances, we may use and disclose your Protected Health Information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of your Protected Health Information, trying to balance the research needs with patients' need for privacy of their your Protected Health Information. Before we use or disclose your Protected Health Information for research, the project will have been approved through this research approval process. We may, however, disclose your Protected Health Information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the Protected Health Information they review does not leave the Thomas Eye Group. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the Thomas Eye Group.

As Required By Law. We will disclose your Protected Health Information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose your Protected Health Information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and Tissue Donation. If you are an organ donor, we may release your Protected Health Information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release your Protected Health Information about you as required by military command authorities. We may also release your Protected Health Information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs your Protected Health Information about you to determine whether you are eligible for certain benefits.

Workers' Compensation. We may release your Protected Health Information about you for Workers' Compensation or similar programs. These programs provide benefits for work-related injuries or illness.

-To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Public Health Risks.We may disclose your Protected Health Information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury, or disability;
• To report deaths;
• To report reactions to medications or problems with products; to notify people of recalls of products they may be using; and
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Health Oversight Activities. We may disclose your Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your Protected Health Information about you in response to a valid court or administrative order. We may also disclose your Protected Health Information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release your Protected Health Information if asked to do so by a law enforcement official:

• In response to a valid court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the Thomas Eye Group; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. We may release your Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release your Protected Health Information about deceased patients of the Thomas Eye Group to funeral directors as necessary to carry out their duties upon the request of the patient's family.

National Security and Intelligence Activities. We may release your Protected Health Information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose your Protected Health Information about you to authorized federal officials so they may provide protection to the President of the U.S.A., other authorized persons, or foreign heads of state, or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your Protected Health Information about you to the correctional institution or law enforcement official. This release would be necessary

1. for the institution to provide you with health care;
2. to protect your health and safety or the health and safety of others;
3. for the safety and security of the correctional institution; or
4. to obtain payment for services provided to you.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding your Protected Health Information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy your Protected Health Information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes and other mental health records under certain circumstances.

To inspect and copy your Protected Health Information that may be used to make decisions about you, you must submit your request in writing to the Thomas Eye Group's Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy your Protected Health Information in certain very limited circumstances. If you are denied access to your Protected Health Information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the Thomas Eye Group will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that the Protected Health Information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Thomas Eye Group. To request an amendment, your request must be made in writing and submitted to the Thomas Eye Group's Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the your Protected Health Information kept by or for the Thomas Eye Group;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an"accounting of disclosures." This is a list of the disclosures we made of your Protected Health Information about you.

To request this list or accounting of disclosures, you must submit your request in writing to the Thomas Eye Group's Privacy Officer. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example: on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request.If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Thomas Eye Group's Privacy Officer. In your request, you must tell us

1. what information you want to limit;
2. whether you want to limit our use, disclosure, or both; and
3. to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Confidential Communications.You have the right to request to receive communications from us on a confidential basis by using alternative means for receipt of information or by receiving the information at alternative locations. We must accommodate your request, if it is reasonable. You are not required to provide us with an explanation as to the basis of your request. Contact the Privacy Officer if you require such confidential communications.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, request a copy from the Thomas Eye Group's Privacy Officer in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for your Protected Health Information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each Thomas Eye Group office. The notice will contain on the first page, in the top right-hand corner, the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Thomas Eye Group Privacy Officer. You may also submit a complaint to the Secretary of the Department of Health and Human Services at The Office of Civil Rights, The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, 1 (202) 619-0257 or toll free 1 (877) 696-6775

To file a complaint with the Thomas Eye Group contact: TEG Privacy Officer, 5671 Peachtree Dunwoody Rd., Suite 400, Atlanta, GA 30342. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF YOUR PROTECTED HEALTH INFORMATION

Other uses and disclosures of your Protected Health Information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose your Protected Health Information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your Protected Health Information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

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