( ) Eye Optique

( ) Dr. Julia Bond Health / Vision Insurance Claim Form: YOUR EYECARE SERVICES WERE PROVIDED BY:

Street DOB: ID#: Your Phone#:

PROCEDURE LOt . SOURCE: CURRENT PROCEDURAL TERMINOLOGY - 4TH EDITION

EXAMINATION SERVICES New Established Fee Intermediate Ophthalmic 92002 92012 Comprehensive Ophthalmic 92004 92014 Office Visit 10 99201 99211 Office Visit 20 99202 99212 Office Visit 30 99203 99213 Office Visit 45 99204 99214 Office Visit 60 99205 99215 Refraction 92015

SPECIAL PROCEDURES Biomicroscopic photography 92285 Chalazion, single 67800 Chalazion, multiple 67801 Color vision extended 92283 Dark Adaptometry extended 92284 Electro-Oculography EOG 93370 ElectroRetinography ERG 93375 Epilation for trichiasis 67820 Foreign body corneal 65222 Foreign body conjunctival 65210 Foreign body eyelid 67938 Gonioscopy 92020 Lacrimal Irrigation 68840 Ophthalmoscopy BIONOLK 92225 Punctal dilation 68800 Punctal Implant (per duct) 68761 Refraction 92015 Retinal Photography 92250 Sensorimotor Evaluation 92060 Trichiasis - electrolysis 67825 Tonometry, serial 92100 Ultrasound - A (with IOL calc ) 76519 Contact B Scan 76512 Visual Fields - limited 92081 Visual Fields - quantitative 92082 Visual Fields - static threshold 92083 Visually Evoked Potential 92280 Unlisted special procedures 92499 Other codes Other codes

LOW VISION AND VISUAL THERAPY SERVICES Amblyopia Therapy - BV 98681 Binocular Vision Therapy non-strabismus - BV 98683 Design/prescribe Spectacle/single element aid - LV 92354 Design/prescribe Compound element aid - LV 92355 Developmental testing - higher functions - DV 95881 Developmental therapy - DV 98684 Neuromuscular Re-education 97112 Ocular Motility Studies 98316 Oculomotor Therapy 98685 Orthoptics - Visual Therapy - per session - BV 92065 Strabismus therapy - rehabilitation - BV 98682 Unlisted neurological/neuromuscular diagnostic 95999

H52.02-Hypermetropia left eye H52.03 Hypermetropia bilateral H52.10-Myopia unspecified eye H52.11-Myopia right eye

H52.12-Myopia left eye H52.13-Myopia bilateral

I-152.201-Unspecified astigmatism right eye

H52.202-Unspecified astigmatism left eye H52.203-Unspecified astigmatism bilateral H52.211-Irregular astigmatism right eye

H52.212-Irregular astigmatism left eye

H52.213-Irregular astigmatism bilateral

H52.221-Regular astigmatism right eye

H52.222-Regular astigmatism left eye

H52.223-Regular astigmatism bilateral

H52.229-Regular astigmatism unspecified eye H52.31-Anisometropia

H52.32-Anisekonia H52.4-Presbyopia

ASSIGNMENT AND RELEASE:

I HEREBY AUTHORIZE THE PHYSICIAN TO RELEASE ANY INFORMATION REQUIRED TO PROCESS THIS CLAIM. I ALSO AUTHORIZE MY INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN, AND I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES.

SIGNED Date

NEXT APPOINTMENT

Eye Optique 10800 Alpharetta Highway

Suite 220 Roswell, Georgia 30076

770-642-7720

( ) Dr. Julia Bond NPI# 1861425506 ( ) Edward Kleinman NPI# 158084961 ( ) Eye Optique NPI# 1912108119

( ) Eye Optique Tax ID# 58-1672353

DIAGNOSIS AND/OR CONCURRENT CONDITIONS: ICD-9-CM

Abnormal Pupil Reflexes 379.40 GLC, Anatom Narrow Angles 365.02 Accomm. Dyst 367.50 GLC, Narrow Intermittant 365.21 Amaurosis Fugax 362.34 GLC, Narrow-Acute 365.22 Amblyopia, Anisometropic 368.03 Headache 784.00 Amblyopia. Strabismic 368.01 Histoplasmosis - POHS 115.02 Aphakia 379.31 H. Simplex, Ophthalmic 054.40 Pseudophakia V43.1 H. Zoster, Ophthalmic 053.20 Arthritis multiple sites 716.99 Hordeolum 373.10 Binocular Dysf 368.30 Hyperemia, Ocular 372.71 Blepharitis 373.00 Hyperphoria 378.43 Blepharochalasis 374.34 Hyphema 921.30 Blepharospasm 333.81 fridocyclitis 364.00 Burn, eye(s) (unspec.) 940.90 Iris, Synechiae (unspec) 364.70 Cataract, late onset PSC 366.14 Keratitis, SPK 370.21 Cataract, late onset Cortical 366.15 Keratoconjunctivitis 370.33 Cataract, late onset NS 366.16 Keratoconus 371.60 Cataract, Incipient 366.12 Macular Degeneration DRY 362.51 Cataract, mature 366.17 Macular Degeneration WET 362.52 Cataract: "After" 366.53 Meibomianitis 373.12 Chalazion 373.20 Metamorphopsia 368.14 Chorioretinal Scars 363.30 Migraine, unspecified 346.90 Chorioretinitis 363.20 Nevus, Choroidal 224.60 Color Vision Defect 368.50 Night Blindness (unspec) 368.60 Conjunctivitis, Mucopurulent 372.03 Normal V65.50 Conjunctivitis, Follicular 372.12 Nystagmus, irreg. EM 379.50 Conjunctivitis, Allergic 372.14 Ocular motor dsyf 378.90 Conjunctivitis, Viral 077.90 Optic Atrophy 377.11 Conjunctival Hemmorrhage 372.72 Optic Neuropathy, Ischemis 377.41 Convergence Excess 378.84 Palsy, NIII 378.51 Convergence Insuff 378.83 Palsy, NIV 378.53 Corneal, Abrasion 918.10 Palsy, NVI 378.54 Corneal, Erosion (RCE) 371.42 Papifledema 377.01 Corneal, Neovascular 370.61 Photophobia 368.13 Corneal, Endo Pigment 371.13 Photopsia 368.15 Corneal, Opacity (idiopathic) 371.21 Pigmentary dispersion 364.53 Corneal Ulcer (unspecified) 370.00 Pinguecula 372.51 Development, disorder 315.50 Pseudo-Tumor, Orbital 379.11 Development, delay in 315.80 Pterygium 372.40 Diabetes, eye manifestations 250.50 Ptosis 374.30 Diplopia 368.20 Pursuit EM deficiency 379.58 Drusen, Disc 377.21 Refractive change, transient 367.81 Drusen, Retinal 362.57 Retinal detach 361.00 Dry Eyes 375.15 Retinopathy (BDR) 362.01 Ecchymosis 921.00 Retinopathy, Hypertensive 362.11 Ectropion 374.10 Retinopathy, CRAO 362.32 Entropion 374.00 Retinopathy, CRVO 362.35 Epiphora 375.20 Retinopathy, BRAO 362.31 Episcleritis, Nodular 379.02 Retinopathy, BRVO 362.36 Episcleritis, Spec 379.09 Retinopathy, Vein Engorgement....362.37 Esophoria 378.41 Retinopathy, Hemorrhage 362.81 Exophoria 378.42 Saccadic EM deficiency 379.57 Exophthalmos 376.30 Scleritis 379.02 Eye, contusion 921.90 Strabismus, accommodative 378.35 Eye, pain in or around 379.91 Strabismus, convergent 378.00 Eye, redness or discharge 379.93 Strabismus, divergent 378.10 Eyelid, inflam. (unspec) 373.90 Strabismus, vertical 378.31 Eyelid, neoplasm (benign) 216.10 Toxoplasmosis - ocular 130.20 Foreign body, corneal 930.00 Thyroid, disorder 242.00 Foreign body, eyelid 374.86 Trichiasis 374.05 GLC. Open Angle - Suspect 365.01 Vision Loss Transient (TVO) 368.12 GLC, Suspect - Ocular HTN 365.04 Visual Field Defect 368.40 GLC, Open Angle - Chronic 365.11 Vitreous detachment - PVD 379.21 GLC, Open Angle - Low Ten 365.12 Vitreous floaters 379.24 GLC, Pigmentary 365.13 Xanthelasma 374.51

MATERIALS Fees Frames V2020 SV Lenses V210_ RT/LT BF Lenses V220_ RT/LT TF Lenses V230 RT/LT Aphakic BF V2430 RT/LT Photochr V2744 RT/LT UV400 V2755 RT/LT Tint V2740 RT/LT Prism V2715 RT/LT Slab-Off V2710 RT/LT Oversized V2780 RT/LT EW CL Aph V2523 RT/LT CL COS V25_ RT/LT

Total Fees:

Accept Assignment:

Adjustments/ Insurance Discounts: S

() YES ( ) NO

Amount Paid Today: ( ) CoPayments

Balance Due from Insurance Co:

Date: Provider / Anthnrized Sionstore

Patient's Name: Date:

Last

First

Address:

City/State Zip

Insurance Company SS#: Email Address:

Note: Retractive diagnosis and eyeglasses are usually covered by eyeglass plans--not major medical.

REFRACTIVE DIAGNOSIS Myopia 367.1 Hyperopia 367.0 Presbyopia 367.4 Astigmatism 367.20

Additional Diagnosis

Patient Financial Responsibility

EyeMed recommends you print this page and have the patient sign and date the below acknowledgment. The document can be kept in the patient's file.

I hereby authorize this vision care provider to apply for benefits on my behalf for covered services rendered by them. I also assign my benefits and request that all payments from EyeMed Vision Care be made directly to the vision care provider. I agree to assume responsibility for full payment pending any remaining balance that is not covered by EyeMed.

I certify that the information I have reported with regard to my coverage is correct. I further authorize vision care provider to release to EyeMed and its agents any information related to this or any related claim.

Member's Signature and Date

HIPAA NOTICE OF PRIVACY PRACTICES

Edward Kleinman, L.D.O. Julia Bond, O.D. Eye Optique

Eye Optique 10800 Alpharetta Highway

10800 Alpharetta Highway

Suite 220

Suite 220 Roswell, Georgia 30076

Roswell, Georgia 30076

(770) 642-7720

(770) 642-7720

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED BY EDWARD KLEINMAN, L.D.O., JULIA BOND, O.D.,

OR THEIR STAFF. PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices describes how we may use and disclose your protected health information (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" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by Julia Bond, O.D., Edward Kleinman, L.D.O., 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 operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to ophthalmic labs. For example, your protected health information 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 protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for optometric care may require that your relevant protected health information be disclosed to the health plan to obtain approval.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, 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: Workers' 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 or determine our compliance with the requirements of Section 164.500.

You may revoke this authorization, at any time, in writing, except to the extent that our practice has taken an action in reliance on the use or disclosure indicated in this authorization. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

Our practice is not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you agreed to accept this notice alternatively i.e. electronically.

You may have the right to have our practice amend your protected health information. If we deny 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 protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice becomes effective on the date signed below.

Signed:

Patient Name (Signature) Date

Patient Name (Print)