Tele-Medical Ophthalmic Testing

Telehealth medical consults are generally not covered at this time: As such, you may be billed and responsible for payment of services

Authorization for Insurance Submission

I agree to pay for the services rendered and the materials fabricated at my request. I request that payment of authorized Medicare / Medicaid / Medigap or other Health / Vision Care insurance benefits be made either to me or on my behalf to Hopewell - Lambertville Eye Associates and/or suppliers for any services furnished to me by that provider of service or supplier. I authorize any holder of medical information or Medicare information about me to be released to the Health Care Financing Administration and its agents or other insurance(s), or Medigap Insurer ( ) , to include any information needed to determine these benefits or the benefits payable for related services.

Responsibility for Payment of Services Rendered

I agree to pay for the services rendered and the materials fabricated at my request and acknowledge that my insurance company can deny payment for services. I agree that if my insurance carrier does not pay Hopewell - Lambertville Eye Associates within 90 calendar days after submission, for services rendered to me, I shall take full responsibility for these charges. If an insurance payment is received after I have reconciled with Hopewell - Lambertville Eye Associates, I will be refunded the amount of payment stated on the “explanation of benefits” provided by my carrier.

Accept Responsibilities for Payment of Diagnostic Procedures Not Covered By Insurance

It is possible that some of the procedures performed during the eye examination may not be covered by my vision or medical insurance. It has been explained to me the importance and reason for these specific eye care procedures which may or may not be covered by my insurance. If these procedures are not a covered benefit, I will accept the responsibility for the payment of non- - covered charges. If I should choose not to have a procedure completed, I will not hold Hopewell - Lambertville Eye Associates responsible for any financial nor medical ramifications due to my actions.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (PRIVACY OF PATIENT RECORDS)

Based on the HIPAA regulations, we cannot share or disclose information from your medical records without your written consent. This implies any and all non - medical or non-licensed healthcare offices or third party vendors. We ask you to sign this form to allow us to disclose only the information required to:

• Have other licensed medical providers who(m) might / will assist in your medical and / or eyecare
• Your insurance carrier in order to process claims and / or a federal or state agency mandates for public health concerns.
• Be able to send you reminders of care utilizing healthcare codes in order to assist in your acquisition of referrals when required.
• If a copy of records are requested by yourself or designated legal guardian, a separate "Record Release" form must be signed by the individual and / or guardian. Records can then be released to the authorized party.
• Your records are held safe within the confines of our office with limited access to doctors and staff.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s Privacy Contact at [84 East Broad Street, Hopewell, NJ 08525 or 16 South Franklin Street, Lambertville, NJ 08530]. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

My physician will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure except: (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. The use or disclosure requested under this authorization will result in direct or indirect remuneration to my physician from a third party.

Visual Acuity at Near

What Number Do you See? Perform Each Eye Separately

Amsler Grid for Macular Disease Screening

Central Vision Loss

If you feel your central vision has been affected perform the Amsler grid below

Visual Fields

View a calendar or clock on the wall approximately 3 ft away.

Stare at the center of the target covering the left eye with your hand.

Photos of the Eyes and Eye

Hold your phone or camera approximately 3 inches from the face and photography the areas around the eyes without a flash. Repeat the photograph with flash on.

Selfie mode is adequate but having someone take the picture is better.

You may need to zoom at 2-3x

Send to 609-213-5008 hopewelleye@kennethdaniels.net

Muscles - Video

Using the video mode about 3-4 inches from the eyes: record of video of the eyes.

1. Look straight at the camera
2. Look slow to your right
3. Look slow to the left
4. Look slow up
5. Look slow down
6. Look straight - stop video

Send to 609-213-5008 hopewelleye@kennethdaniels.net

TO BE COMPLETED BY DOCTOR

If you are a patient, just click SUBMIT below