New Patient Registration Forms

Mack Eye Center
Prinze Mack, M.D.
Shiza Sarfraz, O.D.

257 Monmouth Road, Suite 1B
Oakhurst, NJ 07755

192 Jack Martin Blvd, Unit B4
Brick, NJ 08724

(732) 835-2020
www.mackeye.com

NOTE: If you have a prior eye doctor and need to send records, please contact your prior eye doctor today and have the records faxed to us at (732) 730-5096.

1 Patient Information and Insurance

INSURANCE INFORMATION: Please enter ALL forms of insurance that you have, including secondary policies (i.e. Medicare secondary), and Vision Plans (i.e. Eyemed, VSP, Spectera, etc.)

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Consent to Treatment and Agreement to Financial Policy: I agree that the signature and initials will be the electronic representation of my signature and initials for all purposes when I (or my agent) use them on documents, including legally binding contracts, just the same as pen and paper signature or initial. I attest that the information I have provided above pertaining to my demographic information and insurance policies is accurate.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

MEDICAL HISTORY FORM

Please fill out all sections to the best of your knowledge.

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Please sign below to acknowledge that you have filled out this medical history form to the best of your knowledge and have checked it for accuracy.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

Billing and Financial Policy

PLEASE READ AND SIGN BELOW:

FINANCIAL POLICY: The following is a statement of our financial policy.

1. Patient Information: All patients must complete all of our Patient Information sheets and this form before seeing the doctor. Unless previous arrangements have been made, all payments are due at the time of the appointment. Payment can be made with cash, check, Visa, or Mastercard. We will only bill insurance carriers with whom we participate (have a signed agreement with).
2. Participating Managed Care Insurance: You are responsible to supply our staff with your primary and/or secondary insurance ID card(s) at the time of your appointment. If your insurance company requires a referral from your primary doctor, you must also present this to our receptionist prior to being seen, as we cannot bill your insurance without it. If you do not obtain a referral when your insurance requires one, you will be required to pay for the visit in full. If your insurance requires a copay, it must be paid at the time of the appointment.
At times, your insurance carrier will deny payment for authorized services. If so, you may be asked
to help resolve these issues with your carrier. If you have a deductible, you will be responsible for paying the full amount of the deductible as it pertains to your visit.
3. Non-Participating Insurances: If we do not participate with your insurance, the bill is your responsibility and is due at the time of service. Payment can be made with cash, check, Visa, or
Mastercard.
4. Medicare: We participate with Medicare. We will submit your claim to Medicare. The 20% difference between what Medicare “allows” and what Medicare “pays” will be sent to your secondary insurance if you have one, or to you. You are also responsible for the payment of your yearly deductible.
5.Returned checks: A Fee of $25.00 will be added to your bill if this occurs.
6. Cancellations: If you are unable to keep your scheduled appointment, 24 hours notice of cancellation is required. Otherwise a $25 fee will be made for the time that was reserved for you.
7. Collections: Any outstanding balance for which the patient is responsible is due within 30 days. For every 30 days an account is overdue, a late fee of $15 will added to the account. For accounts that go unpaid past 90 days, late fees will cease and the balance will be sent immediately to collections with a 25% charge.
Thank you for your cooperation in understanding our financial policy. I have read the above Mack Eye Center financial policy and I understand and agree to abide by its terms.

e-signature

I have read the billing policy and understand and agree to its terms.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

e-signature

I have read the billing policy and understand and agree to its terms.

REFRACTION AND CONTACT LENS
FITTING POLICY

REFRACTION POLICY:
During your visit, a refraction may be performed to determine your need for glasses or to evaluate if any further visual improvement can be achieved. This is a necessary and essential portion of your eye exam and in some cases it is the sole reason for the appointment.
However, the refraction is considered a NONCOVERED service by Medicare and many Commercial
Insurance plans.
Our office collects the $40 refraction at the time of service.
If your primary or secondary insurance pays us for the refraction, we will CREDIT your
account. This will be determined when we receive the Explanation of Benefits.

CONTACT LENS POLICY:
The glasses prescription you receive from the Mack Eye Center is NOT a contact lens prescription.
The doctor must examine and fit you with the contact lenses on your eye(s).

A refraction is necessary prior to a contact lens evaluation.
All Soft Contact Lens examination patients will receive a new bottle of approved Contact Lens Multipurpose solution and new case.
There is a fee for this service, even if you are an established contact lens wearer. Similarly to the
refraction policy, the fitting fee is due at the time of service as below. After your contact lens fitting is completed and services incurred are paid for, you will be able to order contact lenses through the Mack Eye Center or be provided with a copy of your contact lens specification.

*NEW Contact Lens patients: To avoid corneal trauma, if you cannot successfully insert the contact lenses in within 20 minutes, we will reschedule you for another training within 1 week. If you require more than 3 sessions to master insertion and removal of the contact lenses, you will be subject to an additional $45 for 3 more sessions. No refunds if the training is unsuccessful.
*NEW Multifocal Contact Lens patients: You will have an opportunity to change your contact lens brand up to 3 times. An additional fee of $45 will apply if you need more sessions.

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I have read and understand the aboverefraction and contact lens fitting policy.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

Ordering Eyeglasses and Contact Lenses

Both locations of the Mack Eye Center offer fashionable Eyeglasses in our Optical Shops as well as Contact Lens ordering.

Our office maintains reasonable prices for Eyeglasses that are competitive with major big box retailers such as Lenscrafters and Pearle Vision, and our Contact Lens prices are very competitive
against major online retailers such as 1800Contacts.

Our optical shop can custom make Eyeglasses and have them ready
for pickup in about 1 week, and Contact Lens orders can be shipped
to your home or office.

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I have read the Eyeglasses and Contact Lens form.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

19 HIPPA Policy for the MACK EYE CENTER

Notice of Privacy Practices & Office Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY
Uses and Disclosures:

• Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
• Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
• Health care operations. Your health information may be used as necessary to support the day- to-day activities and management of Mack Eye Center. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
• Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
• Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
• Other uses and disclosures require your authorization. Disclosure of your health information or
  its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Additional Uses of Information:

• Appointment reminders. Your health information will be used by our sta to send you appointment reminders.
• Information about treatments. Your health information may be used to send you information
  that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.

Individual Rights:

You have certain rights under the federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your protected health information.

The right to receive confidential communications concerning your medical condition and treatment.

The right to inspect and copy your protected health information.

The right to amend or submit corrections to your protected health information.

The right to receive an accounting of how and to whom your protected health information has been disclosed.

The right to receive a printed copy of this notice.

Mack Eye Center Duties:

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices:

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any offce visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information:

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the receptionist or Dr. Mack. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Payment:

Payment is required at the TIME OF YOUR VISIT. We accept cash, check, debit, Mastercard, or Visa. If you have insurance you MUST present your insurance card at the time of your visit. Please notify the office of any address, phone number or insurance changes. Any co-payments are due at the TIME OF YOUR VISIT. There will be a service charge of $25.00 on all returned checks.

**There will also be a $25.00 charge for all NO CALL/NO Show appointments that are not cancelled 24 hours in advance of appointment time. Late fees will be applied to past due accounts over 90 days.

Prescriptions:

Prescriptions should be renewed Monday thru Friday. Twenty-four (24) hour advance notice is
required for phone-in/fax prescription renewals. Please do not call for renewal after office hours or on weekends. Renewals of all triplicate prescriptions require periodic office visits to monitor your progress and prescription use.

Forms:

Please allow up to five (5) working days for completion of your medical forms. Depending on the complexity of the forms, we reserve the right to charge for the completion.

Medical Record:

Due to the rising costs in operating our medical practice, there will be a $20.00 fee plus $1.00 per page charge to copy and/or mail your medical records. Upon payment and receipt of a properly signed authorization, your records will be transferred within ten 10 business days. If you are allowing your lawyer or life insurance company to retrieve copies of your records, the fees stated above apply.

Complaints:

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Mack Eye Center
257 Monmouth Road, Suite 1B
Oakhurst, NJ 07755

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

This notice is effective as of 12/1/2016.

Information To Be Used or Disclosed:

The information covered by this authorization includes (some or all of the fields listed):

Eye exam results, including photos and/or scans, Blood/Radiologic test results, Consultants reports, Information on current or planned medical treatments

Purpose of Disclosure

Information listed above will be disclosed for general information purposes and/or medical decision making. Information listed above will be used or disclosed by Dr. Mack.

*Persons To Whom Information May Be Disclosed: Please make sure you filled out the fields at the top of this form.

Expiration Date of Authorization

This authorization is effective indefinitely unless revoked or terminated by the patient or the patient’s personal representative.

Right To Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Mack Eye Center. You should contact the office to terminate this authorization.

Potential For Redisclosure

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. It may not be possible to ensure your right to the protection of the privacy of this information once Mack Eye Center discloses it to another party.

Rights of the Individual

You may inspect or copy information used or disclosed under this authorization.
You may refuse to sign this authorization.

Effect of Refusing Authorization

If you refuse to sign this authorization, Mack Eye Center will not deny you any treatment except research-related treatment or treatment that you have requested for the purpose of disclosure to others.

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HIPPA STATEMENT: I have read and agree with Mack Eye Center’s HIPPA Notice of Privacy Policy. I hereby authorize Mack Eye Center to furnish to my insurance company or authorizing agency information regarding my protected health information for the purposes of treatment, payments, or health care operations. I further authorize the physician(s) of Mack Eye Center to consult as needed in their sole discretion with other medical providers regarding my medical care.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.

e-signature

I acknowledge the information to be true and request my records be sent to the Mack Eye Center.

By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein.