I, the undersigned, certify that I or my dependents have insurance coverage with the insurance company listed above and assigned directly to Adairsville Eye Associates all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance company for any reason and agree to pay any charges denied by my insurance within 60 days. I hereby authorize the Doctor to release any information necessary to secure the payment of benefits for services rendered. In addition, I also authorize the use of my signature on all insurance claims and permit a copy of this authorization and assignation to be used in place of the original. This assignment will remain in effect until revoked by me in writing.

Patient's certification authorization to release information and payment request. I certify that the information given by me in applying for payment under Title XVIII/XIX of Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration/Divison of Family Services or its intermediaries that carry any information needed for this of a related Medicare claim. I hereby certify all information pertaining to treatment shall be assigned to the physician treating me. I also request payment of any MEDIGAP benefits be made on my behalf to Adairsville Eye Associates for any and all services. I authorize any holder of medical information about me to release to Adairsville Eye Associates any information needed to determine benefits payable for related services.

Check all that apply.

There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Adairsville Eye Associates accepts most insurance plans in both categories: 1) Vision plans (such as VSP and EyeMed) and 2) Medical insurance (such as Blue Cross/Blue Shield and Medicare) Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems). Medical insurance must be used for medical eye care. If you have both types of insurance plans it may be necessary for us to bill some services to one plan and some to the other. We will follow a procedure called coordination of benefits to do this properly and to minimize your out of pocket expense. If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services as allow by the insurance contract. Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance card or Medicare card on file in case we should need it in the future for billing your insurance. I have read and accept these policies.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully. This Notice of Privacy Practices describes how we may use and disclose your protected health information herein referred to as PHI to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" or PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. Uses and Disclosures of Protect Healthcare Information or PHI: Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operations of the physician's practice, and any other used required by law. Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services; this includes the coordination or management of your health care with the third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for hospital admission. Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your Physician's practice. These activities include, but are not limited to, quality assessment activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you of your appointment either by phone or mail. We may disclose your PHI in the following situation without your authorizations. These situations include: as Required by Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity, and National Security, Worker's Compensation, Inmates, Required Uses and Disclosures, Under the law we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate and determining our compliance with the requirements of Section 164-500. Other Permitted and Required Uses and Disclosures will be made only with your consent. Authorization or Opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights: Following is a statment of your rights with the respect to your PHI. You have the right to inspect and copy your PHI: Under federal law, however, you may not inspect or copy the following records; psychotherapy note: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. You have theright to request a restriction of your PHIT: This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment, or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply. Your Physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communication from us by alternative locations. You have the right to obtain a paper copy of this notice from us, upon request., even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have you physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. We reserve the right to change the terms of this notice and will inform you by posting such changes in the office for your convenience. You then have the right to object or withdraw as provided in this notice. Complaints: You main complain to us or to the Secretary of Health Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifiying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before April 14, 2003. We are required by law to maintain the privacy of, and provide individuals with, this notice of legal duties and privacy practices with the respect to PHI. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our Phone Number.