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MANAHANEYE ASSOCIATES

MANAHAN EYE ASSOCIATES535 FORTUNE DRIVE STE. 200 PAPILLION, NE 68046 (402) 934·9033 FAX (402) 934-9506

CELIA R. MANAHAN M.D. ROBERT G. MANAHAN M.D.

PATIENT NAME SEX (circle one) M FLAST FIRST MIDDLEINITIAL

HOME ADDRESS----~C-IT~Y~------------------------S~·l~·RE~-~E~T-AD~D~RE~S~·S~--------------~Z~I~PC~O~I~)I~~------

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AGE DATE OF BIRTH SS •. _

MARITA L STATUS (circle one) M S W D EMAIL ADDRESS _

PREFERREDLANGUAGE _

ETHNICITY:o HISPANIC OR LATINO NOT HISPANIC OR LAlTNO [J PREFER NO r TO ANS WER

RACE:[ AMERICAN INDTAN OR ALASKAN NATIVE

BLACK OR AFRICAN AMERICAN"NATIVE ILAWAI IAN OR OTllER PACIFIC ISLANDER

rJASIANOWl-UTECPREFER NOT TO ANSWER

PARENT/GUARDIAN (circle one) (if under 19 years ofage), _IIOMEADDRESS, ~----~~----~---------------------------HOME PHONE ( ) WORK PIrONE (

SPOUSE CELL PHONE ( , WORK PHONE (

EMERGENCY CONTACTDAYTIME PIIONE ( ), _PRIMARY CARE PIIYSICIAN PHONE (

___________ RELATIONSH IP _

P~NUU~Y/SECONDARYINSUR!\NCE _

INSURANCElTOLDERSEMPLOYER _EMPLOYER'SADDRESS __

INSURANCE IIOLDER'S DATI~ OF BIRTH AND SSN _

IS TTTTSA WORKMAN'S COMPENSATlON ACCIDENT? (circle one) Y N'If ycs, has this becn rcported to your employer and what is the date of the accident? __

WIIO MAY WE THANK FOR REFERRlNG YOU? _

COPAYS ARE COLLECn:!) THE DAY OFYOUR VISIT

SIGNATURE DATE _

OR AUTHORIZED REPRESENTATIVE RELATIONSHI P/TITLE, _

~MANAHANEYE ASSOCIATES

MANAHAN EYE ASSOCIATES535 Fortune Drive Suite 200 Papillion, Nebraska uo.&t5 (402) 934-9033 Fax: (.02) 9:W·9506

Cella R. Manahan, M.D. Robert G. Manahan. M.D.

FINANCIAL POLICYThank you for choosing Manaban Eye Associates, P.c. the following is a statement of our FINANCIAL POLICY. Allpatients must a.cc.ept our FINANCIAL POLICY before receiving treatment. Please understand that full payment of your billis considered a part ,-[your treatment.

METHOD OF PAYMENT; WE ACCEPT CASH. LOCAL CHECKS, VISA AND MASTERCARD. Payment plan maybearranged on an individual basis with the Office Administrator.

_____ REGARDING YOUR INSURANCE: As a courtesy to you, we will submit medical claims to your insurance company.Any balance afrer proem;ng o(o"r claim by your carrier is your ryQOasibjhty, Your ins~ policy is II. contract betweenyou and your insurance company. You are responsible for ve rifying if providers arein..:network with your insurancecompany. We cannot bill your insurance company unless you gi ve us your complete insurance infonnation for cotW1lercialinsurance, Medicare and Nebraska Medicaid. If your insurance information is not ~eived prior to treabnent, then paymentis due in full. It is your responsibility to verify the benefits covered by your plan as the insurance company may not cover allof the services provided to you. If your insurance company has not responded and paid its portion of your account in fullwithin 45 days of the date of service, then the balance will become your responsibility to pay in full by the statement duedate. An Administrative ree of SI 0.00 will be applied to your account if full payment is not received by the statement duedate.

DEFINITIONS:CO-PAYMENT: A fixed dQllar amount set by your insurance contract that is to be paid at the time

ofan office visit. This amount is usually between SIS and 550.

DEDUCTIBLE: An ~dol1ar amount established by your insurance plan that is deducted from insurancebenefits. This amount is your obligation and must be paid prior to health care services.

CO-INSURANCE: A percent set by your insurance plan that is deducted from insurance benefits.This percent usually ranges from 10% to 30% and is your obligation to pay.

REGARDING INSURANCE PLANS where we are a participating provider: All co-pgys, deductibles and co-insurancerequired by your insurance company are due prior to treatment ..

REGARDlNG PERSONAL INJURY: We require payment in full at the lime g[service for personal injury cases. We arenot a party to any litigation suits being filed for pcrsonal injuries. In all cases we require our payment in full and anypayment from litigation is to be sought by you for reimbursement of your medical services.

REGARDING WORK RELATED INJURIES: We will file Worke~ Compensation claims with your employer or youremployer's Workers Compensation insurance carrier. Writte n or telephone authorization is required from your employerprior to treabnent. ifprior quthorization is /WI obtained. you orr rrSDonsible for full pgyment at the time of service. If yourcompany's workers compensation carrier has not paid your account in full within 45 days of your date of service. the balancewill be transferred to your account and it is your responsibility to pay in full by the statement due date.

____ REFRACTIONS ("checking YOIl for an eyeglass prescription"); Refractions may not be covered by some insurance plans.Medicare does not cover refractions. Please consult with your insurance provider If a refraction is performed and not coveredby insurance, you are responsible for the refraction fec.

MISSED APPOINTMENTS: Please notify our office at least three hours in advance if you cannot make your appointmentWe reserve the right to discharge you from our practi cc if you have three no-shows for scheduled appointments.

RETURNED CHECKS. A $25.00 service fee will be added to all checks re turned for insufficient funds. If your check isreturned, you will be required to pre-pay in full by cash, Visa or MasterCard for additional services.

COLLECTIONS. We reserve the right to forward your account to a collec lion agency ifit is dctcnnined to be uncollectible.

I UNDERSTAND AND AGREE TO THE TERMS OF THIS FINANCIAL .POLICY.

SIGNATURE of Patient or Responsible Party PRINT P,'\TlENT'S NAME DATEManahan 1'1 Fin Policy

NOTICE OF PRIVACY PRACTICES

This notice serves to inform YOli of our practice policy regarding the liseand disc/()surc a/your private health in/ormatiun. It is also designed togive YOIl Ull understanding o/yo"r rights to access 0/ yo III' privale heollhinformation and IT!strict IIna"tharized access.

If you have any questions about this Notice please contact Celia Manahan,MD, Privacy Officer.

Thc tenns of this Notice of Privacy are effective April 2003. Manahan EyeAssociates will share patient health infonnation as is necessary to providequality health care and receive rcimbursement for thosc services aspennitted by law. Our otTice is required by law to maintain the privacy ofour patients' health information and to provide patients with this Notice ofPrivacy Practices. Our office will abide by the terms of this Notice so longas it remains in effect and we reserve the right to change the tenns of theNotice of Privacy Practices as neccssary. A copy of any revised notices willbe available in our offier., or, upon request to Celia Manahan, MD, PrivacyOfficer, P.O. Box 609, Bellevue, NE 68005. A copy may be mailed to youraddress maintained on file.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Our office is cOlrunitted to maintain the confidentiality of your healthinformation. However, your health infonnation may bc used and disclosedas customary and reasonable for purposes of treatment, payment, andhealth care operations and pursuant to a signed authorization form. Youhave the right to revoke that authorization in writing unless any action hasbeen taken in reliance on the authorization.

Treatment, Payment, and Health Care Operations. Except as otherwiseprovided, or with your signed consent, our office will use and disclose yourhealth information for purposes of treatment, payment, and as otherwisenecessary and permitted by law, for our health care opcrations. This mayinclude disclosure to another health care provider who, at the request ofyour physician, becomes involved in your treatment, or for purposes ofapproval or reimbursement from you health plan.

Business Associates. At times, it may be necessary for us to provide yourhealth information to certain outside persons or organizations that assist uswith our health care operations, such as auditing, accreditation, legalservices, etc. The business associates are required to sign an agreementstating their fiduciary responsibilities in using this private health information.

Family and Friends. If authorized by you, we will share your privatehealth infonnation with friends and family members to the extent that youauthorize. In the case where you are incapacitated and we feel thatdisclosing omitted health infonnation is in your best interest, we willdisclose such information to family andlor close friends for purposes ofcommunication and decision making.

Appointments and Services. Our office may contact you to provideappointment reminders or infonnation about your treattnent alternatives orother health-related benefit issues. You have the right to require an alternatemethod of communication in writing and may send your request to CeliaManahan, MD, Privacy Officer, P.O. Box 609, Bellevue, NE 68005.

Othcr uses and disclosurcs of your individllal hcalth infonnation, pcnnittedor required by law, m:ly be madc without your consent or authorization :lndare as follows:I.Any purpose required by law;2. Public health activities, such as required reporting of disease, injury. andbirth and death, and for required public health investigation;3. As required by law if we suspect child abuse or neglect; we may alsorelease your individual health infonnation as required by law if we bclievcyou :Ire a victim of abuse, neglect, or domestic violence;4. Ifnecessary, to the Food and Dn.lgAdministration;5. To your employer when we have provided health care to you at therequest of your employer;

6. If rcquired by law to a govcrnmcnt oversight agcncy conducting audits,investigntion, or civil or criminal proceedings;7. If required by a court or administrative ordered subpoena or discoveryrequest; in most cases you will have notice of such release;8. To law enforcement officials;9. To coroners andlor funeral directors consistent with law;10. If necessary to arrange an organ or hssue donation or transplant;I!. If you are a member of the military as required by anncd forcesservices; we may also release your individual health infonnation ifnecessary for national security or intelligence activities; and12. To workcrs' compensation agcncics.

YOUR RIGHTS

1. Restriction on Use and DiscloslIre of Individllal Healtlr Information.You have the right to request restrictions on some of our uses anddisclosures of your health infonnation. We retain the right to refuse suchrestrictions if we believe such termination is appropriate, In the event of arefusal by us, we will notify you. You also have the right to terminate, inwriting, any agreed-to restriction by sending such termination notice toCelia Manahan, MD, Privacy Officer.

2. Access to Individual Health Informatiotl. Vou have the right toinspcction and copying your health infonnation maintaincd by our office.Such a rcqucst must bc made in writing. Plcase scc our writtcn practicepolicy regarding copying patient records and fces associated. Vou mayobtain a request for access fonn from our office. In eertan circwnstanccs,you may not be permitted access (e.g., psychotherapy notes, informationcompiled for legal action, or information subject to prohibition by law).Depending on the circumstances, you may request a review of the decisionto deny access.

3. Amendments to Individual Health Information. Vou have the right torequest in writing that your health infonnation maintained by our office beamended or corrected. Please contact Celia Manahan, MD, Privacy Officer,for questions about amendments to your health infonnation.

4. A,counting for Disdosure of Individllal Health Information. Vou havethe right to request in writing to receive an accounting of certain disclosuresmade by us of your health infonnation after November 14,2005.

COMPLAINTS: If you believe your privacy righ~ have been violated,you may file a complaint with Celia Manahan, MD, Privacy Officer, P.O.Box 609, Bellevue, NE 68005. You may also file a complaint with theSecretary of the U. S. Dept. of Health and Human Services in Washington,D.C. in writing. There will be no retaliations for filing a complaint.

ADDITIONAL INFORMATION

If you have questions or need additional assistance regarding this Notice,you may contact Celia Manahan, MD, Privacy Officer, PO. Box 609,Bellevue, NE 68005.

PATIENTSIGNATURE: _

orAUTHORIZEDREPRESENTATIVE (Title) __

DATE: __ / _

I authorize Manahan Eye Associates to disclose my private healthinfonnation to the following individuals:

NA~lE RELATIONSHIP

NAr-.IE RELATIONSHIP

rATlENT SIGNATURE DATE