od provider manual - luxottica · external chart audit form 180 loss of consciousness and...

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EYEXAM of California, Inc.

OD Provider Manual Revised June 2019

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Welcome to EYEXAM of California! Using the OD Provider Manual We have re-designed this doctor manual with you in mind and we’ve made it as easy as possible for you to navigate. For the best experience, we recommend you use the electronic version of this manual, which is available by contacting the Mission Viejo office. You can search for topics easily and print just the items you need:

The table of contents contains hyperlinks so you can easily see what’s included. Just click the link to go straight to the topic area.

Hyperlinks within the copy will also take you right to other relevant topic areas or allow you to download forms and reference tools.

Please contact the Kathy Cook or the Mission Viejo office if you have any questions and we’ll be happy to assist you. Kathy Cook 949-364-2256 ext. 105 [email protected] EYEXAM of California, Inc. P.O. Box 2756 Mission Viejo, CA 92690

mailto:[email protected]

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OD PROVIDER MANUAL Table of Contents

All sections and topics are hyperlinked for ease of use.

Section 1: CREDENTIALING Doctor Credentialing

Guidelines for Credentialing Optometrists Doctor Credentialing for EyeMed

8 9 11

Section 2: GRIEVANCE ENROLLEE SYSTEM Enrollee Grievance System 16 Suggestion/Complaint Form (English)* 161 Suggestion/Complaint Form (Chinese)* 163 Suggestion/Complaint Form (Spanish)* 165 Suggestion/Complaint Form (Vietnamese)* 167 Review of Grievance Notification Template* 169 Review of Grievance/Follow-up Completion Form Notification Letter* 171 Receipt of Grievance Notification Template* 172 Grievance F/U Completion/Corrective Action Notification Template* 174 Communication of EECA’s Member Grievance Memo* 175

Section 3: CLAIMS Managed Vision Care & Assignment Vision Care Claims 25

Section 4: QUALITY ASSURANCE GUIDELINES Accessibility & Wait Time Surveys 27

Standards of Accessibility 28 Internal Chart Audit Process 31 Physician Referral Audit 32 After Hours Voice Mail Systems & Audit 33 External Chart Audit Process 34 Freedom of Optometric Professional Judgment Memo*

Internal Chart Audit Form* 176 177

Collection of Patient Information Memo* 178 Quality Assurance Follow-up Action Plan Form* 179 Internal Audit Notification 35 Receipt of Follow-up Action Plan Notification 36 External Chart Audit Form* 37 Chart Audit Key 40 Examination Protocol 41 Optomap Retinal Exam Guidelines 55 Standard Clinical Abbreviations 56 Section 5: TAB PRE-APPOINTING PATIENTS TAB/The Appointment Book- Pre-Appointing Patients Reference Guide 60

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Section 6: CONTACT LENS PROCEDURES & FORMS Federal Trade Commission: Contact Lens Rule

Contact Lens Follow Up and Release Guidelines Online Contact Lens Seller Verification Form

64 71 73

Section 7: EMERGENCY PROCEDURES & PHYSICIAN REFERRAL Guidelines for the Management of Patient Inquiries and Ocular Emergencies Emergency Telephone Triage Form

75 82

Blood Pressure Screening and Referral Guidelines 83 Physician Referral Follow-up Log 182 Physician Referral Form* 183 Physician Referral Follow-up Letter* 184

Section 8: INSURANCE Medically Necessary Contact Lens Claim Form*

Medically Necessary Contact Lens Reimbursement Assignment Plans Medically Necessary Reimbursement EyeMed- Request for Low Vision Service/Materials Form

87 88 90 92

Section 9: HIPAA, SUBPOENAS, PATIENT CHART DOCUMENTATION & STORAGE PROCEDURES What is the Health Information & Portability Accountability Act (HIPAA) 94 General Statements & Definitions 98 Disclosure of Personal Health Information 102 Minimum Necessary Use & Disclosure 103 Access by Personnel 105 Marketing 106 Confidential Communication 108 Granting Access to PHI 109 Complaints 118 Amendments to PHI 119 Mitigating Effects of Unauthorized Use 122 Sanctions 124 Prohibiting Retaliation 126 Obtaining Individual Authorization 127 Personal Representatives 130 Communicating with Family & Others Involved in Care 132 Verification 135 Rights to an Accounting 138 Privacy Breach 141 HIPAA- Frequently Asked Questions 143 Notice of Privacy Practice

Instructions for Filing Suspected Child Abuse Report Form SS8572* Suspected Child Abuse Report Form SS8572

151 185 186

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Section 10: EYEXAM OF CALIFORNIA, INC. CORPORATE OFFICE EYEXAM of California Organizational Chart 159

Section 11: REFERENCE FORMS Suggestion/Complaint Form (English) 161 Suggestion/Complaint Form (Chinese) 163 Suggestion/Complaint Form (Spanish) 165 Suggestion/Complaint Form (Vietnamese) 167 Review of Grievance Notification Template 169 Review of Grievance/Follow-up Completion Form Notification Letter 171 Receipt of Grievance Notification Template 172 Grievance Follow-Up Completion/Corrective Action Notification Template 174 Communication of EECA’s Member Grievance Memo 175 Freedom of Optometric Professional Judgment Memo 176 Internal Chart Audit Form 177 Collection of Patient Information Memo 178 Quality Assurance Follow-up Action Plan Form 179 External Chart Audit Form 180 Loss of Consciousness and Anaphylactic Shock 181 Physician Referral Follow-up Log 182 Physician Referral Form 183 Physician Referral Follow-up Letter 184 Instruction for Filing Suspected Child Abuse Report Form SS8572 185 Suspected Child Abuse Report FormSS8572 Exam Equipment Support

186 187

Section 12: APPENDIX OneSight Voucher Program Procedures 189 Blepharitis Handout 192 Cataracts Handout 194 Diabetic Retinopathy Handout 196 Dry Eye Handout 198 Flashes, Floaters & Vitreous Detachment Handout 200 Glaucoma Handout 202 Macular Degeneration Handout 204 Pediatric Eye Examination Guidelines 206 Glossary of Pediatric Procedures

Keratoconus Guidelines Dry Eye Guidelines

210 212 214

Physician Referral Protocol 223 Store & Equipment Maintenance 225

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Section 13: OUR EXPECTATIONS OF YOU Provider Manual 229 11 Plan Information and Enrollment

Speaking of Communications Record Maintenance Out of Office Coverage Names and Logos Insurance Requirements for Independent Contracting Providers Fraud, Waste, Abuse Prevention Getting Paid Non-Covered Services

230 231 232 233 234 235 236 238 239

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Section 1: CREDENTIALING

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DOCTOR CREDENTIALING

All EYEXAM of California (EECA) providers are credentialed at time of hire or when entering into a Vision Care Provider Agreement and re-credentialed annually, when their license is renewed. Newly graduating Optometrists (ODs) may be re-credentialed more frequently based upon their date of birth and when their initial license expires.

As part of the initial hiring process, EYEXAM of California performs two types of credentialing. One is the receipt and review of the ODs CA license. A review of the CA Board of Optometry website is completed to ensure the OD is in good standing. A review of all appropriate paperwork to work in CA is also completed (signed contract, I-9, etc.)

The second part of the credentialing process includes forms for ODs to be credentialed with other plans, such as EyeMed/Council for Affordable Quality Healthcare (CAQH). EECA provides the application for the OD to complete and return to the Mission Viejo office for submittal to EyeMed/CAQH.

o The completed EyeMed ‘request for application’ form is emailed by EECA home office along with copies of the OD’s license(s) and diploma to an EyeMed rep for review and CAQH setup.

o The EyeMed rep emails the new hire a CAQH Pin # and CAQH website information. The new hire logs into the CAQH website and begins the formal credentialing process.

o Once the new hire completes/submits the online CAQH credentialing the 45+ day credentialing countdown begins. Providers are not authorized to see any EyeMed members for EyeMed insurance benefits until they have completed the credentialing process and have received notification from EyeMed that they are active and associated with a location(s).

Monthly, the EECA Master File and Rosters are reviewed. For ODs whose license expires during the month, a review of the CA Board of Optometry website is performed to confirm if the license has been renewed. If not, notifications are sent to the OD and the Senior Eye Care Director (SECD) immediately. An OD is to be taken off the schedule until the license has been renewed.

All updated licenses are printed and a hard copy is kept in the license binder in Mission Viejo Office.

Independent Contracting Providers operating under a Vision Care Provider Agreement must ensure that new providers that are employed or contracted with them or their group will submit EYEXAM’s required credentialing information as soon as reasonably practicable after hire and in no event more than 30 days after the employment or contract begins. Affiliated providers may not provide covered services to EYEXAM Members until they are properly credentialed.

Annually, the ODs are sent packets to be credentialed to various plans, including Medical Eye Services (MES). It is the responsibility of the OD to fill out the forms, the ODs work directly with EyeMed or other plans as necessary.

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GUIDELINES FOR CREDENTIALING OPTOMETRISTS

The Quality Assurance Committee has adopted the following guidelines (and will adopt such others as it may deem prudent) for use by the Plan in evaluating and credentialing optometrists for the Plan to help ensure quality of vision care delivery:

Each Plan Provider must: 1. Hold a valid, unrestricted license to practice optometry in the state of California, with TPA

certification. 2. Be able to, and agree to, perform all of the procedures and meet the minimum standards set

by the Quality Assurance Committee for a complete eye examination, as contained in Part IV Examination Protocol;

3. Have experience in contact lens fitting. 4. Have not been suspended from participation in other health plans or government programs

(EyeMed, Medicare, Medicaid, MediCal, Etc.) The Plan requests that each Optometrist provide a copy of a valid license to practice optometry in the state of California. Moreover, the Chair of the Committee will review the proficiency of each optometrist in meeting the standards set by the Committee in connection with eye examinations at least annually, using the Committee's evaluation of the peer review and in-office reports as a basis. Credentialing/Re-credentialing Process Overview

It is the policy of EYEXAM that all applicant and existing doctors must complete and attest to the accuracy of their CAQH information and consent to the inspection of records and documents pertinent to the credentialing and re-credentialing processes.

EYEXAM’s participating doctor application includes the provision that applicants have the right to request the status of their credentialing and re-credentialing application. The doctor’s rights and EYEXAM contact information is included in the application packet. The doctor can request, in writing, to review and correct information obtained from outside sources for the purposes of initial credentialing and re-credentialing. However, peer review information is confidential and protected.

If the information submitted by the doctor varies substantially from the primary source verification and/or EYEXAM’s network requirements, the applicant is notified immediately.

EYEXAM’s policy also requires that applicant and existing Providers provide complete and accurate information. If the Provider fails to disclose adverse actions, EYEXAM will make multiple contacts with the Provider to obtain the information. Failure to provide this information may result in a denial and/or termination from the EYEXAM network.

As part of the initial and ongoing credentialing process, the Credentialing Committee reviews all Providers with issues, including but not limited to state licensing board disciplinary action, Medicare/Medicaid sanctions, malpractice coverage, adverse Quality Assurance (QA) results, non-compliance with network participation criteria, and patient complaints.

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In the event that a contracted Provider fails to meet EYEXAM’s standards for practice, EYEXAM may institute corrective actions that may include sanctions, implementation and monitoring of a corrective action plan to rectify the non-compliance and/or termination.

EYEXAM has a non-discrimination policy in credentialing of its providers, and the Credentialing Committee members sign a non-discrimination agreement that remains in effect during their term as a Committee member. The statement attests that all decisions made by the committee are based on the Provider’s credentials and EYEXAM network participation criteria and not the doctor’s age, gender, sex, religion, color, creed, ancestry, disability, genetic disposition, height, weight, veteran’s status, gender identity or expression, sexual orientation or race, specialization or special services of the Provider.

The credentialing and re-credentialing process is outlined as follows:

Incomplete applications: EYEXAM notifies the applicant within 30 calendar days of receipt of application

Primary source verification: must be completed within 180 calendar days of Provider signature date and Credentialing Committee date.

Frequency of re-credentialing: occurs every three years in accordance with state and federal requirements and NCQA guidelines.

EYEXAM conducts credentialing/re-credentialing verifications, which include the following:

California State license

Board certification

Education and training

DEA license (if applicable)

Malpractice insurance coverage

Malpractice claims history and/or sanctions

Medicare/Medicaid sanctions via NPDB and EPLS

Attestation of the Providers o Physical and mental status o Lack of impairment due to chemical dependency/substance abuse o No limitations on Licensure and/or felony convictions o No history of loss or limitation of privileges or disciplinary activity o Current malpractice insurance coverage o The correctness and completeness of the application

EYEXAM conducts ongoing monitoring of to verify current licensure and malpractice coverage, as well as the sanction status of the Providers.

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DOCTOR CREDENTIALING FOR EYEMED A) When Hiring New Graduate

1. Confirm Optometrist (OD) has National Provider Identifier (NPI) number. CAQH and EyeMed

process will NOT start without this number. https://npiregistry.cms.hhs.gov

2. Confirm OD credentialed with CAQH. EyeMed process will NOT start without CAQH number. 3. Doctor may go out on the CAQH website and start that process to save time.

https://proview.caqh.org/pr 4. Inform new grad to have these documents/information ready to submit to CAQH:

a) OD diploma b) OD License c) A copy OD Professional Liability Insurance (PLI) d) Make sure Carrier for liability insurance policy is correct, policy number is correct and

the Effective and Expiration dates are correct 5. Make sure work history on application goes back at least 5 years or from date of graduation to

present, if less than 5 years, with NO gaps. If there is time they were not working, there is a place to explain the gap. Any gaps will cause the credentialing process to discontinue.

6. Make sure EyeMed has permission to view the Providers CAQH application. 7. Complete attestation. 8. Once new grad credentialed via CAQH, send EyeMed application to start Provider credentialing

process. 9. The attached EECA sample is highlighted to show what should be filled out on the EyeMed

application. 10. Associate OD (AOD) of Vision Care Provider (VCP) needs to fill out section 1 & 3 and VCP fill out

section 2 with practice information. 11. Store location number is always used rather than the EECA number on application. 12. EECA Tax ID number is always used on application. (Section 2) Do not use the Provider OD’s or

the new hire doctor's tax ID. The only time EECA tax ID NOT used is if Vision Care Plan is NOT related to EECA.

13. Once application is filled out email to [email protected] to complete the credentialing process. Reach out to LuxRetailRequest in one (1) week to check on status so there are no delays.

B) When Hiring Outside OD Already EyeMed Credentialed:

1. Email [email protected] with the OD’s Name and their NPI or EyeMed Provider ID number to add them to each work location. They should appear on the CIAO provider dropdown in a few days.

C) When Hiring Outside OD “NOT” EyeMed Credentialed:

1. AOD needs to fill out section 1 & 3 and VCP will fill out section 2 with practice

information. 2. Store location number is always used rather than the EECA number on application.

https://npiregistry.cms.hhs.gov/

https://proview.caqh.org/pr



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3. EECA Tax ID number is always used on application. (Section 2) Do not use the Provider OD’s or the new hire doctor's tax ID.

4. Once application is filled out email to [email protected] to complete the credentialing process. Reach out to Luxretailrequest in one (1) week to check on status so there are no delays.

D) Section Applies To All OD Categories:

1. Time frame to be credentialed as a new graduate may take 30-45 days because NPI and CAQH must be established then EyeMed process begins. Time frame for an already established OD with NPI and CAQH takes 10-15 days. During this period, OD may not examine an EyeMed patient.

2. The OD that examines the patient must be the same OD to bill EyeMed. There may not be two (2) separate doctors for one transaction.

3. Remember CAQH is a separate entity that confirms Provider information from ProView or Aperture for EyeMed/Assignment clients. Doctor must stay proactive in keeping CAQH up to date.

4. An EECA application is attached as a sample. Do not fax. It must be emailed to [email protected].

5. Sublease doctor fills out Section 2 Primary Office Information and the new hire OD fills out section 1 and section 3.

6. Store location number is always used rather than the EECA number on application. 7. EECA Tax ID number is always used on application. Do not use Sublease or the new hire

doctor’s tax ID on application. (Section 2) The only time EECA tax ID is NOT used is if Vision Care Plan NOT related to EECA.

8. If you want any ODs to work in other locations you must email LuxRetailRequest to add them to that location email number along with their EyeMed provider number or NPI number. You will receive confirmation they have been added.

9. CAQH needs to be updated with an OD’s information when asked to re-attest this ensures ODs are kept credentialed.

10. Doctors will receive emails to remind them to re-attest every 90 days https://proview.caqh.org/pr

11. Doctor will receive confirmation from CAQH and EyeMed separately credentialed. 12. Doctor cannot be EyeMed credentialed unless CAQH credentialed. 13. If doctor is not on your provider drop down in CIAO this means they need to be added or they are

NOT EyeMed credentialed.




https://proview.caqh.org/pr

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Section 2: GRIEVANCE ENROLLEE SYSTEM

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ENROLLEE GRIEVANCE SYSTEM

I. GRIEVANCE PROCESS

EYEXAM of California has an established system to ensure that questions, disputes, and any complaints are given prompt attention. The goal of the Plan is to achieve 100% patient satisfaction. We encourage and empower our trained staff to resolve grievances within the office.

II. HOW GRIEVANCES ARE RECEIVED

Grievances may be submitted directly to EYEXAM personnel at any EYEXAM location during regular business hours. Grievance forms and a description of the grievance procedure is readily available at each office of the Plan and on the Plan’s website. The Plan’s Customer Service Center accepts grievances or related customer service inquiries 24 hours per day, seven days per week via telephone, fax or electronic mail. Grievances submitted to EYEXAM personnel at office locations, to the Plan’s Customer Service Center or through the Plan’s website will be forwarded to the Grievance Coordinator the same business day. The Plan also accepts letters, faxes, or phone calls directly to the Grievance Coordinator at the Mission Viejo Corporate office. A representative is available directly by phone or voicemail Monday through Friday, between the hours of 9:00 a.m. and 5:00 p.m. These phone calls are promptly returned within the same business day. Members may file grievances for at least 180 days following any incident or action that is the subject of the member’s dissatisfaction.

It is the policy of EYEXAM of California that all members are afforded the opportunity to effectively communicate with the Plan’s doctors, technical staff, Grievance Coordinator and customer service representatives, regardless of cultural differences, linguistic limitations, or other communicative impairment. Language Assistance services for limited English proficient members are available without charge to assist in the submission of grievances, communication of the Plan’s response to grievance submissions, communication of general health care matters, or any related customer service issue, including insurance or managed care. Language assistance services are available at EYEXAM offices during regular business hours, or through the Plan’s customer Service center 24 hours per day, seven days per week.

EYEXAM will ensure that there is no discrimination against any member on the grounds that a complainant filed a grievance. III. DOCUMENTATION

When a patient's concern is not resolved at the Provider level, the Grievance Coordinator is contacted and completes or receives a Patient Grievance Form, which is used to document the patient's complaint(s). The Grievance Coordinator forwards a copy of the Grievance Form to the originating office, the Regional Director of Eye Care, and to the Clinical Director/QAC Chairperson, if the grievance concerns clinical standard of care issues. The Grievance Coordinator shall submit a letter of acknowledgment to every enrollee whose grievance is not resolved within 5 calendar days. The letter shall formally acknowledge the date the grievance was received and advise the enrollee of the grievance process and the anticipated time for resolution.

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In collaboration with the Provider, designated Senior Eye Care Director, and Clinical Director, the Coordinator resolves the grievance and communicates the resolution in writing to the enrollee. The Grievance Coordinator will provide a notification letter of the grievance to the Clinical Director within 10 days of receiving it. In addition, the Clinical Director will document review of the grievance for clinical quality issues within 30 days of the resolution letter, confirm the Grievance Coordinator’s initial assessment, and provide recommendations for follow up or corrective action as may be necessary. Corrective action will be documented by the Provider or Senior Eye Care Director, as appropriate, and reported to the Clinical Director. IV. RESOLUTION GOAL The Plan's goal is to resolve a patient grievance within two days. However, the resolution time may vary depending on the complexity of the investigation. The need to speak to an unavailable provider or obtain records or receipts may result in a reasonable delay. Patient refunds are credited immediately for credit card transactions. For cash or check transactions, if cash refunds are available in the office's cash drawer, a cash refund is given. Otherwise, a check is mailed to the patient within ten business days, or other appropriate resolution is made. V. EMERGENCIES AND URGENT GRIEVANCES

The Plan provides for an expedited grievance process to respond to grievances involving an imminent and serious threat to the health of the patient, including but not limited to, severe pain, and potential loss of life, limb, or major bodily function. Upon receiving notice of a grievance involving an imminent and serious threat to a member’s health, the Plan, through the Grievance Coordinator and the Clinical Director, shall do the following:

1. The Plan shall immediately notify the complainant of his/her right to notify the Department of Managed Health Care of the existence of the urgent grievance;

2. The Plan shall provide the complainant and the Department with a written statement on the disposition or pending status of the urgent grievance within 3 days of receipt; and

3. The enrollee’s medical condition shall be considered when determining the response time.

4. If the enrollee’s complaint is outside the scope of services provided by the Plan, as described in the Evidence of Coverage, the enrollee shall be referred to their personal physician or a hospital emergency room.

5. All correspondence or other communication involving urgent grievances shall be documented and retained by the Grievance Coordinator.

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VI. DENIALS

The Plan, as a provider of vision services, is rarely in a position to either authorize or deny services based upon medical appropriateness. The Plan's covered benefits consist of an eye examination including refraction and related ancillary services, as well as follow-up care where indicated. All enrolled members are entitled to the services as set forth in the applicable Evidence of Coverage. No prior authorization is required or necessary before an enrollee can receive services, other than verification of membership. A service denial would occur only when the member is no longer eligible to receive services, or has exhausted his or her benefits with respect to frequency of services under the applicable Evidence of Coverage. If a member were to request a particular diagnostic procedure that is inappropriate or inconsistent with the Plan's standards, any decision to approve or deny a particular diagnostic procedure would be made by the individual optometrist, in accordance with the Plan's Evidence of Coverage and standards of care as established by its Quality Assurance Committee.

VII. RESPONSE LETTER & RESOLUTION To finalize a grievance resolution, a written response is mailed to the patient within thirty days from the day the initial complaint was taken. The written response contains the information required by the Department of Managed Health Care under Section 1368.02 of the Act. The Plan's objective is to have the patient satisfied with the resolution of their complaint. Any grievance involving a denial of service concerning clinical standard of care issues will be referred immediately to the Clinical Director. The Clinical Director will review the appropriateness of the denial, and has the final authority to override any denials of service. The Clinical Director’s Decision will be documented and provided to the patient, the provider, and the Grievance Coordinator. EYEXAM of California will keep in its files copies of all grievances, and the responses thereto, for a minimum of five years. VIII. GRIEVANCE PROCEDURE Customer complaint calls and letters should be processed and documented by the Grievance Coordinator in the following manner:

Record all grievances on the Grievance Log, and assign a classification code or codes for each grievance. All issues or potential issues raised in each grievance should be recorded and classified by category.

Complete a customer grievance form if one has not been received from the enrollee.

Summarize each complaint received and forward the summary to the Office Supervisor and/or Managing O.D. of the location where the complaint occurred, and to the Senior Eye Care Director and Clinical Director if the grievance concerns clinical standard of care issues.

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VIII. GRIEVANCE PROCEDURE (cont.)

The Office Supervisor and/or the Managing O.D. will call the Grievance Coordinator, Senior Eye Care Director and Clinical Director if necessary, within 24 hours to discuss possible resolutions.

The Office Supervisor and/or Managing O.D. will contact the complainant and resolve the problem within 24 hours whenever possible.

The Office Supervisor and/or Managing O.D. will fax a summary of the resolution to the Grievance Coordinator and to the Senior Eye Care Director and Clinical Director if the grievance concerns clinical standard of care issues.

If a grievance is not resolved within five calendar days, submit an acknowledgement letter to the enrollee. Grievances resolved within five calendar days do not require an acknowledgement letter, but still receive a disposition letter as described below.

Ensure all grievances are resolved within 30 days.

The Grievance Coordinator will submit a status report or final disposition letter to the enrollee within 30 days.

If the grievance concerns a denial of treatment, the Grievance Coordinator will forward the appeal to the Clinical Director, and submit an acknowledgement letter to the enrollee within five calendar days.

Record all refunds disbursed to grievance enrollees.

Provide quarterly to the Clinical Director, Senior Eye Care Directors and Board of Directors a summary report of each grievance received for their corresponding region. The reports will be prepared on spreadsheets summarizing and tabulating the numbers of grievances, issue(s) raised in each grievance by classification code, and resolutions for each assigned classification code, and submitted to the Clinical Director and Senior Eye Care Directors one week prior to the quarterly QAC and Board of Directors meetings. The QAC and Board of Directors shall review and discuss the tabulated grievance information at their quarterly meetings.

Address each grievance recorded on spreadsheet above at the Quarterly QAC and Board of Directors meetings.

Provide and document appropriate follow up or corrective actions involving a provider or store location where appropriate.

IX. DESCRIPTION OF GRIEVANCE CATEGORIES Each grievance shall be assigned one or more of the following classification codes according to the issue(s) described in the grievance:

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G1- Doctor/Professionalism: Complaints related to the doctor’s behavior, service, performance & practice:

Sub Categories: G1-a Doctor acted unethically or unprofessionally

G1-b Issue related to Doctor’s demeanor or behavior

G1-c Issues related to Doctor’s hygiene and/or dress

G1-d Doctor refused to see last appointment of the day due to leaving

G1-e Doctor unfamiliar with how the ancillary equipment and/or testing

G1-f Doctor cannot find patient’s chart

G1-g Sexual Misconduct

G1-h Under the influence

G1-i Doctor did not wash hands prior to exam

G1-j Doctor communicated possible diagnosis in a way that caused undue fear

G1-k Doctor unfamiliar with exam equipment

G1-l Doctor did not appropriately answer patient’s questions/concerns

G2- Eye Exam: Complaints related to any component of the pretest, exam, contact lens evaluation, or

ancillary services: Sub Categories: G2-a Associate failed to inform patient of any additional pricing for ancillary services

G2-b Associate seemed to be unfamiliar with the pretest equipment

G2-c Associate failed to clean equipment in front of patient

G2-d Patient was not given appropriate instruction or time when learning to insert/remove new

contact lens

G2-e Patient feels that EYEXAM does not have the most up-to-date equipment

G2-f Patient felt that the equipment or exam/pretest room was dirty

G2-g Patient caught conjunctivitis in the office from dirty equipment

G2-h Patient has allergic reaction

G3- Prescription: Complaints related to any aspect of the spectacle prescription:

Sub Categories: G3-a Prescription incorrect

G3-b Prescription inputted incorrectly in POS system

G3-c Glasses or frame material incorrect

G3-d Optician did not take the adequate time to check patient’s glasses to ensure they were able to

see and fit correctly

G3-e Associate did not adequately address any issues

G3-f Issues the patient may have had with their eye wear

G3-g Patient has allergic reaction

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G4- Service/Associate: Complaints related to the behavior, conduct or performance of an associate, or complaints related to the level of service provided G5- Refund: Complaints related to a refund provided (or not provided) on membership fees, ancillary services or contact lenses G6- Coupon/3rd Party: Complaints related to discounts, rebates or vendor coupons G7- Insurance Billing: Complaints related to the verification, authorization or submission of an insurance claim G8- CL Replacement: Complaints related to exchanged or returned contacts, open boxes G9- CL Release: Complaints related to the dispensing of trial contacts or finalizing the contact lens prescription upon completion of the fitting process G10- Membership: Complaints related to member services, Evidence of Coverage G11- Distribution: Complaints related to the availability, ordering, arrival or follow-up on contacts, glasses and optical supplies G12- Product: Complaints related to the quality or variety of contact lens products G13- CL Prescription: Complaints related to any aspect of the contact lens prescription:

Sub Categories; G13-a Prescription incorrect


G13-c Office doesn’t have the correct trial contacts in stock to try on

G13-d Unable to get a convenient appointment to see the doctor for a CL F/U appointment

G13-e Doctor did not provide the CL Rx at the end of the exam

G13-f Patient upset that they have to come back in for a f/u appointment

G13-g Patient has not been taught how to insert and remove CLs

G14- Pricing: Complaints related to the fess charged for an eye exam/membership, office visit, contact

lens fitting, ancillary services and contacts G15- Clinical Issues: Complaints concerning possible medical quality of care issues, patient incidents

involving product, therapeutic/diagnostic agents, solutions, exam equipment, etc.:

Sub Categories: G15-a Patient contracted infection

G15-b Doctor did not deliver an adequate exam

G15-c Incorrect Diagnosis

G15-d Inappropriate treatment given per diagnosis

G15-e Improper diagnostic procedure

G15-f Doctor provided an incorrect spectacle or CL Rx

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DESCRIPTION OF GRIEVANCE CATEGORIES (cont.)

G16- Miscellaneous: LensCrafters issues, copy of patient chart, copy of Rx, removal from mailing list or advertising, etc…

G17a- Accessibility/Office: Appointment does not start within 30 minutes, ADA complaints G17b- Accessibility/Appointment: Appointment not scheduled within two weeks, patient not scheduled

with doctor requested, lost or incorrectly scheduled appointment G17c- Accessibility/Urgent: Appointment not provided within 48 hours G17d- Accessibility/Emergent: Appointment not provided within 24 hours G18 Appeals: Denial of a service or treatment G19 Denials: Authorization or denial of services based upon medical appropriateness G-20 Expedited: Imminent and serious threat to the health of the patient G-21 Language Assistance Program: Complaints related to access to interpreting or translation services C- Compliment: Positive feedback/recognition of doctor or associate providing exceptional services DMHC Quarterly Grievance Report Web Portal Filings: Grievance classifications shall be reported to the Department of Managed Health Care according to the following categories: Standard DMHC Categories: Coverage: Coupon/3rd party, insurance billing, pricing, membership, appeals, denials, expedited (G6, G7, G10, G14, G18, G19, G20) Medical Necessity: None Quality of Care: Professionalism, eye exam, spectacle Rx, CL Rx, other clinical, (G1, G2, G3, G13, G15) Accessibility: In office wait, appointment wait, urgent wait, emergent wait, LAP (G17a, G17b, G17c, G17d, G21) Service: Service/associate, refund, CL replacement, distribution, product, release (G4, G5, G8, G9, G11, G12) Other: Miscellaneous (G16)

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X. QUARTERLY REPORTS TO THE DEPARTMENT OF MANAGED HEALTH CARE EYEXAM of California will submit quarterly reports to the Department of Managed Health Care describing grievances that were or are pending and unresolved for 30 days or more as required by Section 1300.68 of Title 28 of the California Code of Regulations. The reports will include the information specified in Section 1300.68(f) and be in the format set forth in Section 1300.68(i). Reports will be prepared for the quarters ended March 31, June 30, September 30 and December 31, and submitted to the Department no later than 30 days after the end of each quarter. FORMS & MEMOS: SEE SECTION 10 OR USE HYPERLINKS BELOW Suggestion/Complaint Form (English) Suggestion/Complaint Form (Chinese) Suggestion/Complaint Form (Spanish) Suggestion/Complaint Form (Vietnamese) Review of Grievance Notification Template Review of Grievance/Follow-up Completion Form Notification Letter Receipt of Grievance Notification Template Grievance F/U Completion/Corrective Action Notification Template Communication of EECA’s Member Grievance Memo

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Section 3:

CLAIMS

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MANAGED VISION CARE & ASSIGNMENT VISION CARE CLAIMS EyeMed’s Claims Department handles all aspects of vision benefits claims, including processing of the claim, supporting the systems that allow automation, payment to providers and members and related reporting. EyeMed also operates a LensCrafters-only safety eyewear program and manages relationships with other vision care organizations. Managed Vision Care Claims: EyeMed Vision Care P.O. Box 8504 Mason, OH 45040-7111 Customer Insurance Claims (800) 521-3605 Questions regarding EyeMed Plans (800) 581-3648 Assignment Vision Care Claims (3rd Party):

Assignment 3rd Party Department -4 West Luxottica of America Inc. PO Box 8511 Mason, OH 45040-9987 Assignment Claims Department (877) 313-1752 Any assignment claims, vouchers, plan leads and communication received from a vision carrier should be sent in an Assignment Claims Envelope to the address listed above. Do not submit the following in the Assignment Claims Envelope:

Any EyeMed Vision Care related materials

Payments sent directly to your store by a vision carrier Any assignment payments received by your location should be immediately forwarded to the Assignment lockbox at the following address: Luxottica of America Inc. 14768 Collections Center Drive Chicago, IL 60693 Claims processing for Independent Contracted Providers operating under a Vision Care Provider Agreement will be handled in accordance with the Provider Agreement.

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Section 4: QUALITY ASSURANCE GUIDELINES

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ACCESSIBILITY AND WAIT TIME SURVEYS The Plan conducts accessibility surveys on an ongoing basis to ensure that each office is satisfying the accessibility requirements established by the Plan. “Accessibility” is defined as scheduling virtually all patients requesting an appointment within one week, and “Wait Time” is defined as having enough optometrists to examine all Plan members and walk-in patients within a reasonable time and commencing scheduled exams within thirty minutes of their scheduled appointment time. The Quality Assurance Committee has established the following criteria for when an office does not meet the Plan’s quality of care standards regarding accessibility and wait time. An office shall receive a notification for corrective action when four or more “No” responses are collected on the quarterly survey regarding the following survey questions: 1. Was an appointment available within one week of your requested date? 2. Did the initial tests done by the Doctor’s staff begin within 30 minutes of the time you were promised?

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STANDARDS OF ACCESSIBILITY

I. Standards for Appointment Wait Time and Enrollee Services

EYEXAM Appointment Wait Times

EYEXAM has established the following time frames for appointment wait times and enrollee services:

Urgent and Emergent Appointments* Wait Time

Urgent Care 48 hours

Emergency Care 24 hours

Non-Urgent/Emergent Appointments* Wait Time

New Members/Routine Examinations 7 business days

Appointment for other services to diagnose or treat a vision condition

7 business days

Follow-up Care Within two calendar weeks/15 calendar days (or as otherwise directed by the optometrist)

* EYEXAM does not require any prior authorization for services

New Members/Routine Examinations- Routine examinations for new or returning enrollees will be scheduled within seven calendar days of the initial request for an appointment.

Urgent Care- Urgent care appointments will be scheduled within 48 hours. Emergency Care- Emergency care appointments will be scheduled within 24 hours. Follow-up Care- Enrollees who have been recommended to return for follow-up care will be scheduled within two calendar weeks (15 calendar days) of the appointment for which follow-up care was recommended, or as otherwise directed by the optometrist. Rescheduling of Appointments- When it is necessary for a provider or an enrollee to reschedule an appointment, the appointment will be promptly rescheduled in a manner that is appropriate to the enrollee’s health care needs, and which ensures continuity of care consistent with good professional practice and the Plan’s standards of accessibility.

Interpreter Services- Interpreter services will be coordinated with scheduled appointments and walk-in appointments in a manner that ensures the provision of interpreter services at the time of appointment.

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After-Hours Services- Each Plan office will maintain an after-hours voice mail advising enrollees of the office address and the hours that optometric care is available. In the case of an emergency, enrollees will be advised to contact their personal physician, their nearest emergency medical facility, or to use appropriately the “911” emergency response system.

Customer Services- Customer service representatives will be available at Plan offices to answer enrollee questions during normal business hours. The waiting time for an enrollee to speak with a Plan customer service representative knowledgeable and competent regarding the enrollee’s questions will not exceed ten minutes. Enrollees may also contact the Plan Grievance Coordinator during or after hours by telephone or electronic mail. Inquiries received after hours will be responded to by a Plan customer service representative the following business day.

II. Standards for In-Office Wait Times Enrollees with Appointments- Examinations for enrollees with scheduled appointments will begin within

30 minutes from their scheduled appointment time. Walk-in Enrollees- Enrollee’s without scheduled examinations will be seen as soon as practicable, or scheduled for the next appointment at a time convenient for the enrollee. Walk in patients will not be seen before scheduled patients. Enrollee’s presenting to the office with urgent or emergency care needs will receive expedited scheduling consideration, appropriate for the nature of the enrollee’s condition and consistent with good professional practice.

III. Description of the Plan’s System for Monitoring and Evaluating Accessibility Appointment Scheduling and Wait Time- The Plan will conduct a quarterly telephone survey of a minimum of 1500 enrollees to determine compliance with the Plan’s scheduling and wait time standards. Respondents will be asked to confirm whether they pre-scheduled their appointment, whether an appointment was offered within two weeks, and whether the examination commenced waiting thirty minutes of the scheduled appointment time. Results will be reported for each office with responding enrollees. Any office receiving four or more negative responses for appointment availability or wait time in a given quarter will receive appropriate notification for corrective action. Enrollee Grievances- Enrollee grievances will be monitored for potential accessibility issues, including routine, urgent and emergency appointment scheduling, and in-office wait time. When applicable, Plan offices or providers will receive appropriate notification for corrective action as part of the grievance resolution process. After Hours Services- The Plan will audit the after-hours voice mail at each Plan office on a quarterly basis to ensure that appropriate after-hours notification is consistently available. Any deficiencies will be communicated to the offices and providers with appropriate notification for corrective action. Evaluation and Follow-Up- The audit results for appointment scheduling, wait time, grievance and after hours services will be provided to the Clinical Director, the Quality Assurance Committee and Plan management in conjunction with other quarterly assurance reporting.

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Deficiencies will be promptly communicated in writing to the affected offices and providers. The communication will identify the issue(s) that resulted in the deficiency, and require a report of corrective action. Deficiencies shall be corrected by the optometrist and/or ancillary staff under the direction of the SECD and Clinical Director, as appropriate. A report of corrective action will be provided to the Clinical Director within 30 days from notification of the deficiency. The Clinical Director will review the corrective action reports and may conduct additional follow-up as necessary.

IV. Standards for Number and Distribution of Optometrists Ratio of Plan Providers- The ratio of enrollees to staff, including health professionals, administrative and other supporting staff, shall be such as to reasonably assure that all services offered by the Plan will be accessible to enrollees in a timely manner, appropriate for the nature of the enrollee’s condition and consistent with good professional practice. There shall be at least on full-time equivalent optometrists to each 2,000 enrollees. Location of Plan Offices- The location of Plan offices providing vision services shall be within reasonable proximity of the business or personal residence of enrollees, and so located as to not result in unreasonable barriers to accessibility. The service area for each office is defined to include all geographic areas within 15 miles or a 30 minute drive from the location.

FORMS & MEMOS: SEE SECTION 10 OR USE HYPERLINK BELOW Freedom of Optometric Professional Judgment Memo

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INTERNAL CHART AUDIT PROCESS

The internal chart process was created and approved by the EYEXAM of California Quality Assurance

Committee, in accordance with the regulations of the Department of Managed Health Care. The purpose of the internal chart audit is to ensure that every patient receives a quality eye examination,

consistent with EYEXAM protocol and professionally recognized standards of care. The audit also helps

ensure that patient care is appropriately documented.

All full time employed and Independent Contracted Providers must be audited semi-annually by their

respective Senior Eye Care Directors (SECDs), or other licensed optometrists. The Internal Audit for the

1st half will be due in July. The Internal Audit for the 2nd half will be due in January of the following year. In order to evaluate the full time Associate Doctors, the MODs or the contracted provider holding the

sublease shall have previously prepared an evaluation of their associate doctors, and shall provide the

same to the SECDs. The SECD, Clinical Director, or MOD may randomly audit any full-time associate

doctor on an as needed basis. Audits must be documented on the Internal Audit Form (EEM09 Section

4), with copies distributed to the doctor who received the audit, the SECD and the Clinical Director.

The following four categories are evaluated during each internal chart audit:

1) Subjective: history and chief complaint 2) Objective: pretests, diagnostic tests, eye health exam and clinical signs

3) Assessment: diagnosis

4) Plan: treatment, prescriptions and/or referral

Two spectacle exam patients and one contact lens patient are reviewed at each audit. Each of the above

four categories have a point value of one to three. A score of three indicates that the Doctor's care for

that patient is outstanding and meets the standard of care as described in the EYEXAM of California

Provider's Manual Section 4 titled "Examination Protocol." A score of two indicates that the care is

average and meets the criteria of the examination protocol, but more attention should have been given

to this category. A score of one indicates that the care fails to meet the minimum standard. The

maximum total score for each chart audit is 12, and a minimum of eight is required to pass. Any chart

with a total score under eight or a one in any category will be considered unacceptable, and require the

preparation and implementation of a Follow-Up Action Plan (Section 3.6).

In the case of an audit not meeting the standards discussed above, the SECD, MOD, and/or AOD will

work together to complete a Follow Up Action Plan (EEM10 Section 4). A copy of the chart, the Follow-

Up Action Plan, and the Internal Audit Form must be forwarded to the Clinical Director within 15 days

from the date of the audit. The first follow up is a coaching and is intended to address any deficiency and

improve performance in order to maintain the necessary standard of care. A subsequent audit failure

within one year will result in a documented associate counseling or default. A third failure within one

year may result in further counseling and/or termination.

Audits that meet the standards should be mailed to the Clinical Director no later than 15 days following

the close of each quarter. The mailing address is 29 The Shops at Mission Viejo, Mission Viejo, CA 92691.

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PHYSICIAN REFERRAL AUDIT The Physician Referral Audit was created by EYEXAM of California, Inc.'s Quality Assurance Committee, in accordance with the regulations of the Department of Managed Health Care. This audit directly reviews the documentation that is necessary to ensure appropriate referral and follow up for any of our patients that may need care outside the scope of optometry. The following five areas will be reviewed quarterly, during the SECD’s regular office visit: 1. Is the Referral Log being maintained properly? 2. Are all returned referral letters filed or documented in the patient record? 3. Are proper follow up methods being used and documented? 4. Are all urgent referrals followed up on within 24 hours? Passing scores must meet standards in three out of four categories, or 75%. Any audit that does not meet the 75% criteria will be considered below standards. For those doctors not meeting standards, their SECD will meet with the doctor to implement a follow up action plan that focuses on the corrective action. A copy of the internal audit and the follow up action plan (EEM10) must be forwarded to the Clinical Director within 15 days from the date of audit. The first follow up is a coaching and is intended to address any deficiency and improve performance in order to maintain the necessary standard of care. A subsequent audit failure within one year will result in a documented associate counseling. A third failure within one year may result in further counseling and/or termination. Audits that meet standards should be mailed to the Clinical Director no later than 15 days following the close of each quarter. The mailing address is 29 The Shops at Mission Viejo, Mission Viejo, CA 92691.

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AFTER HOURS VOICEMAIL SYSTEMS AND AUDIT EYEXAM of California is required by the Department of Managed Health Care to develop and implement an after-hours voice mail monitoring system. The Mission Viejo home office conducts quarterly audits of the after-hours voicemail system at each location. Four areas will be addressed as follows: 1) Does the office have an automated after hours voice mail message? 2) Does the voice mail message advise patients of the office location and hours of service? 3) Does the voice mail message advise patients how to schedule an appointment? 4) Does the voice mail message advise patients who need immediate after hours assistance to contact their personal physician, nearest emergency center, or to call 911?

Each office voice mail should have the following message: “Thank you for calling the EYEXAM of California Office at ___________. If you are having an eye emergency and need immediate medical attention, please contact your regular physician, the nearest emergency medical facility, or call 911. The closest emergency facility to our location is at (name, address, phone #, major cross streets). If you have additional questions or would like to schedule an eye examination, please call back during our regular business hours at (your office #) For your convenience we are open (list hours). Thank you for calling EYEXAM of California.” Independent Contracted Providers may substitute their practice identification name for EYEXAM of California Passing scores must meet standards in 4 out of 4 categories, or 100%. Any audit that does not meet the 100% criteria will be considered below standards. For those doctors’ not meeting standards, their SECD will meet with the doctor to implement a follow up action plan that focuses on the corrective action. A copy of the internal audit (EEM09) and the follow up action plan (EEM10) must be forwarded to the Clinical Director within 15 days from the date of audit. Audits that meet the standards should be mailed to the Clinical Director no later than 15 days following the close of each quarter. The mailing address is 29 The Shops at Mission Viejo, Mission Viejo, CA 92691.

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EXTERNAL CHART AUDIT PROCESS

Clinical chart audits are conducted as part of our Quality Assurance program. The purpose of the audit process is to ensure consistent delivery of care to all patients. Areas of opportunity are also identified through the audits.

The Quality Assurance committee has determined a minimum acceptable score of 85% for all external chart audits. Doctors failing to meet this standard will undergo an evaluation by the Senior Eye Care Director (SECD) or the Clinical Director. Any doctor failing to meet established standards may face disciplinary action up to and including termination.

The external chart audit is conducted annually and is performed by an outside optometric consultant. This consultant may be asked to conduct special audits as well.

Five charts (three spectacle exams and two contact lens exams) are randomly selected for each doctor. The charts are audited against the QAC established guidelines. External chart audit results are reported to the doctor by a report prepared by the Clinical Director. Failed audit results are reported directly to the doctor by the SECD.

FORMS & MEMOS: SEE SECTION 10 OR USE HYPERLINK BELOW Internal Chart Audit Form Collection of Patient Information Memo Quality Assurance Follow-up Action Plan Form

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INTERNAL AUDIT NOTIFICATION

To: Dr.___________________________, Vision Care Provider, EYEXAM of CA #_______ Dr.___________________________, Senior Eye Care Director, Region____________ From: Dr. Cindy Chiang, Clinical Director Date: _____________________ Re: Quality Assurance Standards and Follow-up Action Plan

The EYEXAM of California Quality Assurance Committee, in accordance with the requirements of the California Department of Managed Healthcare, has adopted the following means of alerting both the Senior Eye Care Directors (SECDs) and the Doctors when an office and/or a Doctor does not meet the Plan’s quality of care standards in one or more of the following the categories. Please be advised that this memo services as notification that during Q____, 201___ your office did not meet the Plan’s standards in the following categorie(s). ___Accessibility ___Internal Audit ___Wait Time ___Grievances ___External Audit Other_______________ ___MD Referral ___After Hours Voice Mail You and your Vision Care Provider (VCP)/Senior Eye Care Director (SECD) must complete the Follow-up Action Plan (EEM09) to identify the issue(s) that created the deficiency(s), the steps you will follow to correct them and the time requires to complete the Action Plan. The completed Follow-up Action Plan should be distributed as follows: The white copy is to remain with the Vision Care Provider (VCP). The canary copy is to be filed by the Senior Eye Care Director (SECD) in their office. The pink copy is to be sent back to the Clinical Director for approval within 30 days of the date of this letter. If you have any questions, please contact the Clinical Director at the corporate address listed below. Or call her at 714-225-5612; you can also contact her by email at [email protected].

29 The Shops at Mission Viejo, Mission Viejo, CA 92691-6513


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RECEIPT OF FOLLOW-UP ACTION PLAN NOTIFICATION

To: Dr.____________________________, Vision Care Provider, EYEXAM of CA #___ Dr.____________________________, Senior Eye Care Director, Region______ From: Dr. Cindy Chiang, Clinical Director Date: ________________ Re: Receipt of Follow-up Action Plan This letter is to notify you that I have received (doctor’s name) transmittal regarding the Q____, 201___ (category of Internal Audit) and the steps to eliminate this issue: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please inform me immediately if there are any additional deficiencies concerning this issue(s). If you have any questions, please contact the Clinical Director using the contact information, listed below. 714-225-5612 [email protected]

29 The Shops at Mission Viejo, Mission Viejo, CA 92691-6513


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EXTERNAL CHART AUDIT Year_________

Date of Audit_______________________________________ Doctor______________________________________

Office_____________________________________________ Auditor_____________________________________

Exam Exam CL Exam CL

Question COMMENTS

1. HX 15 25 2. CC 6 10

3. VA 6 10

4. Rx 6 10

5. DEP 3 5

6. COL 3 5

7. VF 3 5

8. IOP 3 5

9. BP 3 5

10. EXT 3 5

11. PUP 3 5

12. EOM 3 5

13. CT 3 5

14.. NPC/NPA 3 5

15.AMS 3 5

16.RET 3 5

17. REF 6 10

18. SL 6 10

19. OPL 18 30

20. AUX 15 25

21. ASSESS 6 10

22. PLAN 18 30

23. CL/HX x x 3 x 6

24. KER/TOPO x x 2 x 4

25. FIT x x 5 x 10

26. F.U. x x 3 x 6

27. PI x x 4 x 8

28. NS DOC x x 2 x 4

Total Missed 157 268 WHITE COPY-Managing O.D. YELLOW COPY- Regional Director Eyecare PINK COPY- Clinical Director EEM05 Rev. 9/18

3 Chart Audit Scoring 5 Chart Audit Scoring Total Total 157 - # Missed (___________________) =__________________ Points 268 - # Missed (______________) =_____________________ Points Total Points (___________________) = __________________% Total Points (______________) = ___________________% 157 OD Score 268 OD Score

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EXTERNAL CHART AUDIT KEY – EYEXAM OF CALIFORNIA, INC.

All Patients- Possible Points per Chart Audit

# Key Points 1. HX 5 Is patient history filled out appropriately? Demographic data: name, address, DOB, and

Gender (-.5pt). Telephone Number (-.5pt.) Language Preference (-.5pt). Employer

/Occupation /Insurance information (-.5pt). COMIA Patient Authorization Form (-.5pt).

Ocular history (-.5pt). Systemic history (-.5pt). Medication use/Allergies to medication (-

.5pt). Family history (-.5pt). Returning Patients: Is there a patient signature indicating no

change in history since last exam, with date of last exam clearly documented on the

history form (-5pt)? Indicate “none” if a question does not apply to the patient. Any

sections left blank will have points automatically deducted.

2. CC 2 Is a chief complaint registered and further history detailed? Discussion of patient's

current visual status (-.5pt), visual needs (-.5pt), any recent or current ocular symptoms (-

.5pt), and use of eye glasses or contact lenses (-.5pt).

3. VA 2 Are unaided (-1pt) and aided acuities (-1pt) accurately taken and noted?

4. Rx 2 Are current glasses neutralized (-1pt)? Is lens type documented (-1pt)?

5. DEP 1 Has depth perception been performed and recorded properly (-1pt)? New patients only oonly 6. COL 1 Has color vision been tested for each eye (-1pt)? New patients only

7. VF 1 Have visual fields been tested, printed and properly recorded for each eye ( -1pt)?

8. I0P 1 Has tonometry been performed for each eye (for NCT, 2 times for each eye) and

intraocular pressure been recorded (-.5pt)? Has time been recorded (-.5pt)? If Informed

Refusal signed, no point deduction.

point deduction. 9. BP 1 Has blood pressure been taken and accurately recorded for all patients over 18 years or

for patients under 18 years when indicated by history or findings (-1pt)?

10. EXT 1 Has observation of external ocular and facial areas been documented ( -1pt)?

11. PUP 1 Has pupillary response been recorded (-1pt)?

12. EOM 1 Has ocular motility been noted (-1pt)?

13. CT 1 Has ocular alignment been recorded (-.5pt)? Has method of performing cover test been

recorded (-.5pt)?

14. NPC/

NPA

1 Has near point of accommodation ( -.5pt) and near point of convergence (-.5pt) been measured and recorded, if indicated? No point deduction if not indicated.

15. AMS 1 Has Amsler grid, if indicated, been tested for each eye (-1pt)? No point deduction if not

indicated. (Indications see Section 4 Examination Protocol-2i)

16. RET 1 Have retinoscopy/auto-refraction/wavefront aberrometer findings been recorded (-1pt)?

17. REF 2 Has an accurate refraction been performed and recorded with resultant distance (-1pt)

and near acuities (-1pt)

(-1pt)? 18. SL 2 Have slit-lamp exam findings been noted (-1pt.) and expanded on when appropriate (-1pt.)?

19. OPL 6 Has ophthalmoscopy been performed and have appropriate findings been recorded

(-2pt)? Has dilated ophthalmoscopy been performed when indicated (-2pt)?

Was informed refusal to dilation signed when indicated (-2pt)? (Indications see Section 4

Examination Protocol 3)

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20. AUX 5 Have auxiliary tests been performed if indicated? (-1pt./test). Other tests when

applicable with max of -5 total.

21. ASSESS 2 Has appropriate impression been formed and noted? Was a medical diagnosis

documented (-1pt)? Was a refractive diagnosis documented (-1pt)?

(-1pt)? Was a refractive diagnosis documented (-1pt)? 22. CON 6 Have conclusions regarding all complaints, symptoms, suspicious and/or abnormal

findings been addressed appropriately in the diagnostic impressions and patient

education? Was a refractive treatment prescribed (-1pt)? Was eyewear purpose, lens

material, lens design and other applicable lens treatment recommended (-1pt)? Was a

medical treatment prescribed when applicable (-1pt)? Was patient educated about

treatment options, visual and ocular health status in relation to his/

her symptoms and complaints (-1pt)? Has a time been recommended for re-exam (-1pt)?

Has appropriate referral been made (-1pt)? No point deduction if not indicated.

Total 46 Contact Lens Patient — Possible Points per Chart Audit

# Key Points

23. CL HX 3 If patient has prior history of contact lens wear, has previous experience with

contact lens been documented, if possible? (-1pt each for lens type, wear modality). If no

prior history, have reasons for interest & intended use of CL been documented (-1pt)?

24. KER/ TOPO

2 Has keratometry/topography been performed or printed out (-2pt)?

25. FIT 5 Is there proper documentation regarding diagnostic fitting results and/or the

performance of the lenses at time of dispensing? (-1pt each for lens type & parameters,

VA, comfort, OR if not BCVA, SL evaluation of fit).

26. F.U. 3 Have there been adequate follow-up examinations accompanied by proper

documentation: VA (-1pt), fit (-1pt), subjective response (-1pt)? No deductions if doctor

has indicated no need for follow up, ok to release CL Rx. (Contact Lens Follow-up and

Release Guidelines Section 6)

27. PI 4 Is there proper documentation regarding contact lens care, including care system (-1pt),

wear schedule (-1pt), wear modality (-1pt), re-exam recommendation (-1pt)?

28. NS

DOC

2 Have all "No Shows" been notified & documented on the chart?

Total 19

Note: If any item is not applicable or not indicated, points will NOT be taken off. If any section of the chart is not

legible, points for that section will be automatically deducted.

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Chart Audit Key—Clinical Abbreviations

HX History

CC Chief Complaint

VA Visual Acuity

Rx Neutralization

DEP Depth Perception

COL Color Vision

VF Visual Fields

lOP Intraocular Pressure

BP Blood Pressure

EXT General External Observations

PUP Pupil Responses

EOM Extraocular Muscles

CT Muscle Balance (Cover Test)

NPC/NPA Near Point of Convergence and Accommodation

AMS Amsler Grid

RET Retinoscopy

REF Refraction

SL Slit Lamp

OPL Ophthalmoscopy and Dilated Ophthalmoscopy

AUX Auxiliary Testing

ASSESS Assessment

PLAN Plan

CL HX Contact Lens History

KER/TOPO Keratometer/Topography Readings

FIT Evaluation of fit

FU Follow Up

PI Patient Instructions

NS DOC No show Documentation

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EXAMINATION PROTOCOL

Patient Examinations and Care

Our goal is to always provide the highest quality of optometric care to each patient. The procedure that follows represents the minimum standards of protocol needed to achieve this goal.

1. Preliminary Testing Objectives of Preliminary Testing: Obtain accurate results for the doctor, as the remainder of the examination process is based

upon the preliminary testing. Provide excellent patient service.

Control patient flow to maximize patient satisfaction and accessibility to services.

All of the following pre-testing steps must be performed by a technician on each patient, on an annual basis, unless otherwise stated, results of the pretest are recorded on the Patient Record and permanently included in the patient file.

a) Disinfect all equipment

b) Patient History To begin a walk-in patient, ask the patient to fill out only the name and address section of the information form. This information should already be filled out if the patient had a scheduled exam. Tear off the duplicate copy of the patient's name and address section and set aside. Another technician can begin a patient file, as the patient is being pre-tested. Before pre-testing begins patient insurance and eligibility should be verified. Escort the patient directly to pre-test and complete the Patient Information form by asking the patient the various medical history questions that appear on the form. The objective of completing the Patient Information form with the patient is to gain control of the patient flow and obtain an accurate patient history in a timely manner. In the event that collecting the patient history during pre-test is not possible (i.e. pre-test room is full), allow the patient to complete this information on their own. For reference, Side 1 of the Patient Record includes an administrative "Patient Information" section, and a "Patient History" section.

Examination results will be recorded on Side 2 of the Patient Record. First, the technician who performs the pre-testing should write his or her name in the box labeled "TECH". Next, enter the patient's chief complaint or reason for the visit in the space provided.

Perform each of the numbered tests below, and record results in the spaces marked by the corresponding numbers in the "Patient Record — Side 2".

For efficient and reliable pre-testing, it is important that the technician spend the needed 20- 30 seconds prior to the testing to explain to the patient how we perform each test and its purpose. All associates should be familiar and comfortable with the testing techniques.

c) Visual Acuity Measure and document visual acuities for all patients before engaging in any further procedure: or pre-testing for purposes of liability. Test and record both uncorrected and corrected monocular acuities for both distance and near vision using these procedures:

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Distance Acuity UNAIDED: First test the right eye unaided without glasses. Instruct the patient to cover the left eye with the paddle occluder. Ask the patient to read the smallest line possible without squinting. Encourage the patient to read a lower line, until they miss 50% of the line.

Record on the Patient Record, in the section marked "Unaided Far", the lowest line that was read correctly, i.e. "20/20" or "20/40", etc. If one letter on the line was missed, for example, on the 20/40 line, enter "20/40 -1"; if two letters were missed, enter "20/40 -2", and so on. If the vision is worse than "20/400," document the vision in terms of "count finger, hand motion, light perception, or no light perception," and allow the doctor to elaborate. Repeat the process with the left eye, having the patient cover the right eye with the paddle occluder.

Near Acuity UNAIDED: First perform the visual acuity test unaided, on the right eye with the left eye covered. Hold the reading card in front of the patient at a 16 inch test distance or a comfortable reading distance. Instruct the patient to read the smallest line, he or she can see. Encourage the patient to read a lower line, until they miss 50% of the line. Repeat the procedure for the left eye unaided.

Record the results as with distance acuity in the "Unaided Near" section of the Patient Record.

Distance Acuity AIDED: Now, measure distance acuities aided with the patient's current distance glasses.

Helpful Hint: If the patient wears only reading glasses, you do not need to complete, aided distance acuity. Document N/A.

Test the right eye first, then the left eye. Follow the same procedure as with unaided testing. Be sure the eye is completely covered.

Record the results in the section marked "Aided Far" on the Patient Record.

Near Acuity AIDED: If the patient wears a reading prescription, half-eyes or bifocals, measure the patient's visual acuity at near with the reading glasses on. Hold the reading card in front of the patient at a 16 inch test distance or a comfortable reading distance. Test the right eye first, then the left eye.

Record the results in the "Aided Near" section of the Patient Record.

d) Blood Pressure Blood pressure should be a standard testing measure for all patients over 18 yrs. or for patients under 18 yrs. when indicated by history or findings. Check the blood pressure prior to tonometry to minimize the effect of patient anxiety on the results. Record findings on the Patient Record; do not discuss any findings with patients. Let the doctor relay the findings.

Blood pressure should initially be taken with the automated wrist cuff, if available. Recommended units include the Omron Digital 652, CP#3013034. See instructions below:

Position the wrist cuff according to the instructions with the unit.

Set the "Preset Pressure Switch" to 220 mmHg. (Note: the "Preset Pressure Switch" is set to 220 mmHg because the switch should be set approximately 60 mmHg higher than the patient's Systolic blood pressure).

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d) Blood Pressure (cont.)

Position the patient's wrist at approximate heart level while the patient is sitting and Push start.

Other recommended units are the Welch Allyn Arm Cuff, CP#3029248. See instructions below:

Position cuff on arm according to instructions with the unit.

Press the start/stop button.

Record finding as described below. (Please refer to Section 7 Blood Pressure Screening and Referral Guidelines)

Examples of findings:

120/80 RAS @ 3pm indicates 120/80 right arm sitting at 3pm.

120/80 LWS @ 3pm indicates 120/80 left wrist sitting at 3pm

e) Depth Perception, New patients only Test binocularly, using the customary reading prescription. Hold the picture straight at 16 inches in front of the patient or at a comfortable reading distance. Provide good lighting. Polarized glasses must be worn over reading glasses, if applicable.

When using Stereo Fly tests start with the number one circle and ask the patient to indicate which circle is floating off the page. Proceed with the remaining circles until the patient misses. Record the last correctly named circle in seconds of stereopsis according to the answer key.

f) Color Perception — Ishihara Plates, New patients only Testing should be done monocularly and documented as such. Use all 15 plates for each eye individually and document findings for each eye.

Plate 1 is a demonstration plate and is not counted in the results. For the remaining fourteen test plates, record on the Patient Record the number correctly named out of the total number of plates shown for each eye. For example, record "OD 7/14" when the patient correctly identifies seven out of the fourteen plates with the left eye, or "OS 10/14" when the patient correctly identifies ten plates.

g) Auto-refractor/Auto-keratometer/Wave front aberrometer Complete the auto-refraction test. Record the results according to doctor preference:

Attach a printout of the test results to the patients file and/or write the results in the

"Retinoscopy" section of the Patient Record and check the "AR Reading" box, write the results in the “Keratometry” section of the Patient record.

h) Tonometry Perform tonometry on all patients, including children. If cooperation is not adequate, as may be

the case with very young children, the optometrist should perform tactile tensions.

Take 2 to 3 readings per eye to ensure accuracy. Note the time and the results on the Patient Record. if tonometry readings through NCT are consistently over 22 mmHg, please have doctor repeat tonometry using Goldmann application.

Exceed the expectations of our patients.

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h) Tonometry (cont.)

Perform the following tests on every patient to maintain our high clinical standards.

If the patient is unwilling to have the test, inform the doctor. Please place an unsigned "Informed Refusal - Glaucoma" form in the patient's chart, the doctor will consult with the patient and if still refused, the doctor will have the patient sign the "Informed Refusal."

After both the patient and doctor have signed and dated the form, give the yellow copy to the patient and retain the white copy in the patient file.

i) Peripheral Visual Fields For patients under 40 years of age:

Insert a trial lens equal to the distance Rx. You may ignore the distance Rx if it is between plano

to -3.00 diopters.

Ignore the cylinder if it is between -0.25 to -1.50 diopters.

For patients over 40 years of age:

Insert a trial lens equal to the reading Rx. To obtain this, refer to the chart below. Add this to the patient's distance Rx to get the new trial lens power.

Age Add Power 40 — 49 +2.00 50 — 60 +2.50 Over 60 +3.00

Ignore the cylinder if it is between -0.25 to -1.50 diopters.

To obtain valid results it is important to:

Ask the patient to blink regularly Make sure the patient is comfortable Ensure that the trial lens is close enough to the patient so that the lens doesn't obstruct the

patient's peripheral vision

Monitor the blind spot Remain with the patient as much as possible, as you will need to reinforce fixation and

monitor the patient's positioning Retest isolated missed points with point clusters.

At the conclusion of the test, record the results as follows: Print out all visual field test results for doctor to review and sign.

j) Current Glasses Analyze current spectacles and record the data. Include sphere, cylinder, axis, and add, if applicable. Check the appropriate box(s) to indicate whether lens designs are bifocal, trifocal or progressive.

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2. Optometrist's Minimum Visual Evaluation Objectives of Examination: Provide the highest quality examination

The following examination protocol is the minimum acceptable standard of care. Following the pre-testing conducted by the technician, the doctor must complete the following visual tests for each patient and record the results on the Patient Record. Record the results for each of the following tests on the Patient Record in the letter-keyed areas, which correspond to the lettered instructions below.

a) Review Patient History/Pre-Test Results Review the patient history and the results of pre-testing. Have any test repeated if results seem inconsistent. If a patient declines a test, document the decline on the chart and have the patient sign the informed refusal when applicable.

b) Address Symptoms Each symptom reported by the patient on the "Patient Information" form or listed as a chief complaint needs to be addressed on the Examination form. Possible symptoms include: headaches, floaters, flashes of lights, etc...

c) Muscle Balance Depending on the patient's age, visual signs and symptoms, and preliminary test results,

appropriate tests of ocular motility, binocular visual function at distance and near, and accommodation are incorporated into the examination. The procedures that may be used to assess the patient's muscle balance include: Ocular motility and alignment

Vergence amplitude and facility

Accommodative amplitude and facility

Associated phoria

Record findings on the Patient Record and check the appropriate box to indicate how findings were obtained

d) Extraocular Muscles Check the appropriate box and fully address and document any abnormalities when appropriate.

e) NPC/NPA Perform as indicated

Document near point of convergence and near point of accommodation if indicated; NPC and/or NPA is indicated; if the patient has any near point symptoms.

f) External

Check "Normal" if normal, otherwise fully address and document any abnormalities when appropriate.

g) Pupils Check the appropriate box and fully address and document abnormalities when appropriate.

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h) Peripheral Visual Fields Evaluation Indications for performing a visual field:

Last documented normal visual field was more than 2 years ago.

The patient is over 60 years of age.

NCT is greater than 20 mm Hg in either eye.

NCT readings of the two eyes differ by 4 mmHg or more.

The prior visual field was abnormal for missed points, fixation losses, false positives or false negatives.

Positive patient or family history of optic nerve or retinal disease.

Abnormal color vision test results.

Abnormal Amsler Grid results.

Positive symptoms of visual loss.

Abnormal neurological functions.

Worse than 20/20 best corrected visual acuity in one or both eyes in the absence of obvious explanation.

Document the results of the visual field on the examination form as either "normal" or "abnormal." If it is "abnormal," the corresponding box of "See Print Out" should also be checked off. There should also be an assessment documented. Note to doctor: If it is discovered that the patient is aphakic, please ensure that the proper trial lens was used, if not, ask the technician to repeat the test. All tests should be performed with the foveal threshold on and the central reference level at 34 db.

i) Amsler Grid Perform as indicated

Indications for Amsler Grid Testing: VA less than 20/20 in the absence of non-retinal pathology.

Evident or suspected sub-retinal or intra-retinal fluid.

Drusen, excess pigmentation or hemorrhage in the macula.

Macular or paramacular depigmentation.

Retinal traction of the macular or paramacular area.

Pallor or atrophy of temporal rim of optic nerve.

Optic nerve drusen.

Anomalous color vision suggestive of macular disease.

Any symptoms of haze over letters while reading.

Any symptoms of letters missing or distortion.

Any complaints of bubble, halo, or haze over the center of view.

Any complaints of spots, oily film, or smeared colors in the center of view.

If the test result is abnormal, locate and sketch the distortion or missing areas on the Amsler Grid Recording Chart. Add the patient's name, test date and eye tested on the Recording Chart. On the Patient Record, check the appropriate "See Amsler" box.

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j) Retinoscopy

If the auto-refractor readings seem unreliable, then perform and record retinoscopy findings. Ensure that either the actual retinoscopy findings or the auto-refractor (AR) findings are recorded, and check the appropriate box.

k) Refraction Record the results of the subjective refraction. In addition, you will need to document "Add" power as "0" and not as plano, when no add power is indicated. Also document monocular visual acuities.

l) Keratometry/Auto-Keratometry Perform on all contact lens patients. Perform on non-contact lens patients as indicated. Record and address distortion if any exists. Document steep k, flat k, and axis of steep or flat k.

m) Slit Lamp Check boxes, if findings are normal, document angles, fully address and document any abnormalities.

n) Ophthalmoscopy Check boxes, if findings are normal fully document and address any abnormalities. Document the time and type of drop used per the Dilation Guidelines.

o) Assessment/Medical & Refractive Diagnosis Check the appropriate boxes in the Medical diagnosis and Refractive diagnosis sections.

p) Plan/Recommendations

Address all of the patient's ocular needs based on lifestyle, occupation, and any other visual needs or problems, and prescribe accordingly.

q) Patient Education/Handouts

Check the appropriate boxes as per discussion with patient and handouts given.

r) Return Visit/Doctor Document when the patient is recommended to return next and the reason for the visit, such as DFE, CL F/U, red eye F/U, IOP check, VF testing, or cycloplegic refraction. Annual exams are recommended for all patients unless ocular and medical reasons indicate otherwise. Exam form should always be signed by the examining doctor.

s) Notes/Auxiliary Testing

Use this space for any additional documentation required for the above tests. Examples of auxiliary tests are cycloplegic refraction, threshold visual field exam, or prism evaluation. IOP's should also be taken through GAT if IOP is >22 mmHg through NCT, or if IOP's obtained through NCT have a difference of >4mmHg between the eyes. Blood pressure should be repeated on the contralateral arm 5 minutes later if findings are higher than normal or if one suspects false high readings with the automated cuff. (Section 5.4 BP Screening and Referral Guidelines)

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Upon completion of the evaluation, the O.D. must always record a diagnostic Assessment and note a Plan. All questionable or abnormal exam findings and chief complaints must be addressed in the Assessment and Plan sections. If the auxiliary testing(s) cannot support the diagnostic Assessment and the best corrected vision, the patient should be referred to a specialist for further evaluation.

3. Dilation Guidelines Dilation is indicated when the patient exhibits one or more of the following criteria.

Patients who had never had dilation before.

Patients new to EYEXAM of California.

Vision not correctable to 20/20 or better with no obvious history or explanation. Myopia of >-4.00 diopters.

Any symptoms suggesting possible posterior segment pathology such as floaters, flashes, distortion, curtains, or visual field defects.

Patients with known systemic disease such as diabetes or hypertension.

Patients with a recent history of head or eye trauma. Patient with a history or family history of retinal or optic nerve pathologies such as

glaucoma, ARMD, or retinal degeneration. Poor view of optic nerve, macula or posterior pole through an un-dilated pupil.

A comprehensive dilated fundus examination is recommended as follows:

Once every two years until the age of sixty, unless risk factors indicate more frequent dilation.

At one-year intervals after age sixty

Cautions to dilation include:

Shallow, potentially occludable angles History of an allergy to the dilation drops

Concern that a patient must perform potentially hazardous visual tasks within several hours following dilation

Pregnancy and nursing

Patients who decline dilation after consultation with the doctor should be advised that undetected pathology may result in loss of vision. Dilated ophthalmoscopy may be deferred to a more opportune time if the patient has visually demanding tasks that may be compromised by dilation. The patient chart must be thoroughly documented. Proper follow-up must be completed and documented to assure every effort has been made to complete the dilation.

When an indicated dilation is not performed, chart documentation must explain the reason. If the patient refuses dilated ophthalmoscopy, note this on the chart. Thoroughly document any advice to the patient regarding their need for dilation and dilated ophthalmoscopy, and the patient's response. An Informed Refusal of Dilation form must be completed if the dilation is indicated because of risk factors and the patient is unwilling to undergo dilation at the initial visit.

Patients with occludable angles or previous allergic reaction to DPAs may be referred to an ophthalmologist for evaluation. Document the chart thoroughly.

In the event of an adverse reaction such as angle closure or allergic response; contact the nearest ophthalmologist or urgent care.

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After both the doctor and the patient have signed and dated the Informed Refusal of Dilation form, give the yellow copy to the patient and retain the white copy in the patient file.

The California Board of Optometry has approved the following diagnostic agents in the examination of human eyes:*

Topical Anesthetics

Proparacaine HCL 0.5%

Benoxinate HCL ........ 0.4% '

Pipericaine HC 2.0%

Benoxinate HCL (including in combination w/ fluorescein)0.4%

Mydriatics

Phenylephrine HCL .......... 2.5%

Hydroxyamphetamine HBr.....1%

Cycloplegics

Cyclopentolate1.0%

Homatropine HBr 5.0/%

Atropine Sulfate 0.5% Tropicamide 1.0%

Combination

Paremyd 1%/.25%

*The percentages that follow each of the above chemical names denote the maximum concentration that may be used for the sole purpose of the examination of the human eye or eyes for any diseases or pathological condition (Sections 3041 and 1560, Business and Professions Code).

To ensure continuity of care, it is important that patients returning for dilation are scheduled with the original examining optometrist.

4. Retinal Photography Retinal photography is recommended for patients that exhibit one or more of the following criteria:

All new patients that have not had photos taken by an EYEXAM of California, Inc., doctor.

Any patient that shows changes from original photos.

Any change in a patients or immediate families' medical history.

Any symptom of possible retinal or optic nerve pathology. Any vision uncorrectable to 20/20, any complaints of distortion, any unexplainable color vision

defects, any visual field defects.

Myopia of › -4.00 diopters.

Any patient with systemic disease/disorders that can affect the retina.

Any patient taking medication with possible side effects. Any patient with positive family history of ocular disease such as glaucoma or macular

degeneration.

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5. Contact Lens Fitting The most professional approach to developing new contact lens patients is to educate the patient as to their options. All discussions with patients concerning their eye health, general health, and contact lens options must be documented on the examination or contact lens fitting form. Doctors must advise patients of the benefits, risks and alternatives of contact lens wear.

Record the following information on the Contact Lens fitting form:

Keratometry for each eye or on examination form.

Trial lenses used; appearance of fit, over-refraction and acuity.

Subjective and objective observations (comfort, fit, vision)

Parameters of the final lens fitted, dispense date, type of care kit, and appropriate wearing schedule with follow-up appointment date.

(See Section 4 External Chart Audit Process and External Chart Audit Form)

When dispensing lenses; make the best use of your available lens inventory while protecting the eye health of the patient.

For new Contact Lens wearers, please provide each patient with a copy of the Lens Care and Handling Sheet for Soft or Gas Permeable/Hard Lenses or document instructions.

Contact Lens Follow-up Guidelines:

a. EYEXAM of California, Inc. has established minimum standards of contact lens care to protect and maintain patient eye health. Be certain to emphasize the wear modality and follow-up guidelines at the time of each fitting, and again during the follow-up visits. The Doctor must document at each follow-up, whether or not the prescription can be released. Please document this clearly on the CL follow-up form.

For all Contact Lenses: For new wearers, advise a wearing time of 4-5 hours the first day, with the addition of two

hours per day up to 12-14 hours maximum. Schedule follow-up care per the guideline chart.

Cosmetic/Tinted Contact Lenses Trials: b. A non-member non-patient may try on colored lenses only with a valid prescription or become a patient by having an examination from EYEXAM of California, Inc.

Please also read Section 6 Contact Lens Procedures and Forms.

6. Prescription Release/Expiration Policy Patient prescriptions are documented on the EYEXAM of California, Inc. form. Spectacle Rx: Each patient must be provided with a signed prescription for glasses based on the results at completion of the examination. Give the patient the white copy of the Rx for his or her reference, the yellow copy for use by the eyeglass dispenser, and retain the pink copy in the

patient file.

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The expiration date must be noted on the prescription. A two year minimum expiration date for spectacle prescription is required unless a specific health or ocular related reason is documented.

Contact Lens Rx: All EYEXAM of California, Inc. doctors and technicians strive to provide the highest quality eye care. We follow the professional guidelines of the American Optometric Association with regard to annual comprehensive examinations and contact lens progress examinations. Contact Lens Progress Examinations are necessary to evaluate a patient's vision and eye health, as well as the contact lens fit and cleanliness. To make it easier for our patients to keep their scheduled follow-up appointments, contact lens progress visits are free during the first six months after the initial exam. The Final Contact Lens Prescription cannot be determined until after several weeks of successful wear. Sometimes side effects from contact lenses do not show until after several weeks of wear, in which case it may be necessary to change the patient's wearing schedule or the contacts at a progress exam. Side effects can happen even if a patient has worn contacts for years without a problem. The doctor will determine the final contact lens prescription at the scheduled progress visits.

Upon the completion of the fitting of the contact lens, we must give the patient a copy of the patient's contact lens prescription. We must do so automatically without any request from the patient as we may not require the patient to make such a request.

The contact lens prescription must include all the following:

Name of the patient.

Date of the examination.

Issue date and expiration date of the prescription. The name, postal address, telephone number, and facsimile telephone number of the

prescriber.

The power, material, or manufacturer or both of the prescribed contact lens.

The base curve or appropriate designation of the prescribed contact lens.

The diameter, when appropriate, of the prescribed contact lens.

In the case of a private label contact lens, the name of the manufacturer, trade name of the private label brand, and, if applicable, trade name of equivalent brand name.

The issue date of the prescription is the date on which the patient receives a copy of the prescription at the completion of a contact lens fitting. The Federal Trade Commission has expressly stated that there is only one issue date for any prescription, and the patient cannot alter the issue date by requesting additional copies of the prescription after the issue date. The issue date is important because that is the date from which the expiration period of the prescription is legally measured.

Contact Lens prescriptions should expire one year from issue date. If the specific health needs of a particular patient require a less than one year contact lens prescription expiration date, then the doctor may write a prescription with such a shorter expiration date. However, the doctor must then also do three things:

1. Document in the patient's medical record the specific reasons for the medical judgment in

sufficient detail to allow for review by another qualified professional in the field.

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2. Maintain this documentation for no less than three (3) years and have it available to the Federal Trade Commission for inspection.

3. The shorter expiration date can never be less than the time period you recommend for a medically necessary reexamination of the patient.

Annual Comprehensive Examinations are necessary for contact lens wearers. Even if there is no change in the patient's vision, or the prescription, annual exams are necessary to make sure contact lens wear is not adversely affecting the patient's eye health. If a patient's contact lens prescription is over one year old, EYEXAM of California, Inc., will not provide the patient with replacement contact lenses until an annual comprehensive examination has been completed.

Please also read Section 6 Contact Lens Follow Up and Release Guidelines.

7. Documenting Patient Care A number of forms and documents have been developed to assist you in documenting patient care

and compiling a detailed "paper-trail" of each patient's history and interactions with our office. Be certain to use all appropriate forms with each patient, secure signatures where needed, and distribute copies as required.

For patients who have completed their initial visit with documentation on the Patient Examination Form, use the Continued Patient Record form to document subsequent recheck visits and findings, as

well as ongoing communications with the patient.

Enter full details of each visit on the Continued Patient Record. Be certain to obtain the signature(s) of the technician and/or doctor involved at the conclusion of the entry. As always, chart notations should be clear and legible.

In addition, document all conversations with the patient — whether written, in person, or by phone, in the patient file. Each entry must include the date, contents of the communication, and the associate's initials.

If regarding an appointment, document the results of the conversation in the appointment book.

If the conversation concerns other matters of patient care, document the discussion and recommendation(s) on the Continued Patient Record form.

If there is a need to transfer patient records to another office, or release records to the patient or a third party, follow the procedures detailed in Section 8.10 Patient File Release Guidelines.

8. Using Clinical Abbreviations When making entries in a patient file, use the uniformly acceptable clinical abbreviates, which are considered industry standard. All associates should be familiar with these abbreviations and use them regularly so colleagues can correctly interpret previous findings and patient care with ease.

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Clinical Abbreviations:

HX History CC Chief Complaint VA Visual Acuity Rx Neutralization DEP Depth Perception COL Color Vision VF Visual Fields IOP Intraocular Pressure BP Blood Pressure EXT General External Observations PUP Pupil Responses EOM Extraocular Muscles CT Muscle Balance (Cover Test) NPC/NPA Near Point of Convergence and Accommodation AMS Amsler Grid RET Retinoscopy REF Refraction SL Slit Lamp OPL Ophthalmoscopy and Extended Ophthalmoscopy AUX Auxiliary Testing ASSESS Assessment PLAN Plan

CL HX Contact Lens History KER Keratometer Readings FIT Evaluation of fit FU Follow Up PI Patient Instructions NS DOC No show Documentation

9. Continuity of Care As much as possible, all follow up appointments should be scheduled with the doctor who performed the original exam. If a patient insists on seeing a specific doctor, this information needs to be noted. If we are unable to schedule the patient with the doctor of choice, we need to let the patient and the doctor know. Whenever doctors have a change in schedule, this information needs

to be communicated to the office staff as early as possible so that they can go through the schedule and make courtesy calls to the patients who may be affected by the schedule change.

Transition all patients that are interested in looking at eyeglasses at LensCrafters to a retail associate. Please take a moment to briefly describe your recommendations to the associate to ensure a seamless experience for the patient/customer.

10. Exam Frequency The Quality Assurance Committee recommends that infants have their first exam by six months of age, followed by an annual exam thereafter.

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Persons in certain high risk categories should follow their optometrist's recommendation on how often they need professional care. These include:

Birth to age 5—Premature or low birth weight infants; infants given oxygen at birth; difficult or assisted labor, which may be associated to fetal distress, low APGAR scores; those whose mothers had rubella, toxoplasmosis, venereal disease, herpes, cytomegalovirus, AIDS, a history of substance abuse or other medical problems during pregnancy; those with a high refractive error, anisometropia; those with known or suspected central nervous system dysfunction evidenced by developmental delay, cerebral palsy, dysmorphic features, seizures, or hydrocephalus; those with a family history of eye related disease, retinoblastoma, congenital cataracts, metabolic or genetic disease, strabismus or congenital eye disorders.

Ages 6 to 9 years—Children failing to progress educationally or exhibiting reading or learning disabilities; those with known or suspected central nervous system dysfunction evidenced by developmental delay, cerebral palsy, dysmorphic features, seizures, or hydrocephalus; those with a family history of eye related disease, retinoblastoma, congenital cataracts, metabolic or genetic disease, strabismus or congenital eye disorders.

Ages 10 to 18 years—School age children/teenagers with any refractive error associated with growth spurt, such as "school myopia"; those with a high refractive error, anisometropia, strabismus; wearing contact lenses.

Ages 19 to 60—Persons diagnosed with diabetes or hypertension, those who have a family history of ocular disease (e.g., glaucoma, particularly those of African American descent; macular degeneration) or those who work in highly visually demanding or eye hazardous occupations; taking prescriptions or non-prescription drugs with ocular side effects; wearing contact lenses; who have had eye surgery; with other health concerns or conditions.

Ages 60 and older—Persons diagnosed with diabetes or hypertension; those who have glaucoma, macular degeneration, or cataracts; those taking prescription or non-prescription drugs with ocular side effects; wearing contact lenses; who have had eye surgery; with other health concerns or conditions.

For all ages—Patients with ocular disease, those with systemic diseases having ocular manifestations or those taking prescription or non-prescription drugs with ocular side effects; Diabetic retinal exams should be performed at the diagnosis of diabetes at any age, and no less than yearly thereafter.

* Please refer to American Optometric Association Guidelines Recommended Eye Examination for Pediatric Patients and Adults

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OPTOMAP RETINAL EXAM GUIDELINES

The standard of care for the examination of the fundus is generally considered to be a dilated exam with

the use of the binocular indirect ophthalmoscope. Clinicians who are experienced with examining the dilated fundus using binocular indirect ophthalmoscope and 90 D slit lamp exams, as well as Optomap, have the found the preferred method that affords the greatest certainty of not missing a lesion is the "both is best" approach.'

The EYEXAM of California Quality Assurance Committee recommends that Optos imaging should be recommended to patients who exhibit one or more of the following:

1. All new patients to an EYEXAM of CA location.

2. Any patient that exhibits retinal changes from most recent Optos images. 3. Any patient with a retinal finding, even in the case of a benign finding.

4. Any patient with a systemic condition that could affect the retina.

5. Any patient with a positive family history of retinal disease. 6. Any patient uncorrectable to 20/20, complaints of distortion, 7. Any unsupported color vision defects.

8. Any visual field defects.

9. Any patient with recent history of head or eye trauma

Optomap is also recommended for all patients who return for an annual exam. If the patient presents for

a routine check-up, has no relevant history, normal visual acuity, IOP, and field screening, as well as high quality Optomap that appears normal in every way, the clinician may decide no other procedures are

indicated. Hence, Optomaps are utilized at the beginning of the fundus exam, and often direct the next

step, or may signal the end of the fundus exam for that visit. Although both Optomap and dilated fundus

exam is best, both may not be essential in every case on every visit,'

Sherman, J. et al. 2007. Panmamic Ophthalmoscopy: Optomap Images and

Interpretation. Thorofare, NJ.: Slack Incoporated.

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V —cc

STANDARD CLINICAL ABBREVIATIONS

AC Anterior chamber D Lens diopters

ACIOL Anterior chamber intraocular lens

DBL Distance between lenses

Add Add power DD Disc Diameter

APC Apical clearance DFE Dilated fundus exam

APT Apical touch Dk Permeability coefficient

AR Autorefraction DPA Diagnostic pharmaceutical agent

ARMD Age related macular degeneration

DX Diagnosis

AT Artificial tears DS Diopter sphere

A/V Ratio of arterial to venous diameter

EOM Extraocular muscles

BD Base down EP Esophoria

BI Base in ER Emergency room

BID Twice a day ET Esotrope

BF Bifocal lens FA Fluorescein angiography

BO Base out FB Foreign body

BU Base up FDT Frequency doubling technique

BCVA Best corrected visual acuity F/F Flashes, floaters

BP Blood pressure FHX Family history

C Centration FT Flat top

C With correction FTFC Full to finger counting

R20 L20

VA with correction FU Follow up

CC Chief complaint GAT Goldmann applanation tonometry

C/D Cup/disk ratio Gtt Drops

CF (VA) Count fingers HA Headache

CL Contact lens check HBA1C Hemoglobin A1c

CN Cranial Nerve HBP High blood pressure

C/O Complaining of HCL Hard contact lenses

COPD Chronic obstructive pulmonary disease

HM Hand motion (VA)

CT Cover test HT Hypertrope

CT Computed tomography HTN Hypertension

HX History PCIOL Posterior chamber Intraocular lens

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V—sc

sc

IOL Intraocular lens PCO Posterior capsular opacity

IOP Intraocular pressure PCP Primary care physician

K Keratometry PD Pupillary distance

<K Angle Kappa PERRLA Pupils equal, round reactive to light and accommodation

LASIK Laser assisted in-situ keratomileusis

PH Pinhole (VA)

LEE Last eye exam PHNI Pinhole no improvement

LP Light perception PO Orally

LVE Limbal vessel engorgement PRK Photorefractive keratectomy

MRx Manifest refraction PRN As needed

MEM Monocular estimation method PSC Posterior subcapsular cataract

MHX Medical history Pt Patient

mmHg Millimeters of mercury PVD Posterior vitreous detachment

MRI Magnetic resonance imaging PX Prognosis

NaFl Fluorescein sodium q. Every (Ex.q2h.)

NCT Non-contact tonometry q.d. Once a day

NKDA No known drug allergies QID Four times a day

NKMA No known medical allergies RAPD Relative afferent pupillary defect

NLP No light perception RD Retinal detachment

NPA Near point of accommodation Ret. Retinoscopy

NPC Near point of convergence RGP Rigid gas permeable lens

NS No show appointment RK Radial keratotomy

NSAID Non-steroidal anti-inflammatory

RPE Retinal pigmented epithelium

NSC Nuclear sclerotic cataract RTC/RV Return to clinic/visit

OCT Optical coherence tomography RX Final prescription

O.D. Right eye RX Glasses check

OMD Ophthalmologist Sc Without correction

ONH Optic nerve head R20 L20

VA without correction

on K Uniform clearance SCL Soft contact lenses

O.S. Left eye SLE Slit lamp evaluation

OTC Over the counter Sol’n Solution

O.U. Both eyes S/P Status post

PAL Progressive addition lens SPK Superficial punctuate keratitis

STAT Immediately

SV Single vision lenses XT Exotrope

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SVP Spontaneous venous pulsation YAG Yttrium aluminum gamet

SX Symptoms 3-9 Staining @ 3 and 9 o’clock

TBUT Tear break up time Prism diopter

TF Trial frame Change

TF Trifocal lenses Convex lens

TID Three times a day - Concave lens

TP Trial pair ♂ Male

TTN To the nose ♀ Female

TX Treatment

µng Ointment

UV Ultraviolet

VA Visual acuity

VEGF Vascular endothelial growth factor

VF Visual field

VT Visual training/therapy

W/ With

W /O Without

WD Working distance

WI Walk-In

WNL Within normal limits

WT Wearing time

WTT Wearing time today XP Exophoria

Please refer to Optometry.org NBEO part II Clinical Abbreviations

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Section 5: TAB: PRE-APPOINTING PATIENTS

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Note: Pre-appointments should only be made with the patient's permission. Since patients are not accustomed to pre-appointments with eye doctors, extra emphasis may be required to ensure they remember making the appointment.

O P P O R T U N T I E S

Pre-Appointing Patients

During Intake: Introduce concept of regular eye exams

1. Give the patient a copy of the Vision Council of America brochure. 2. Explain that the Dr, recommends annual eye exams. 3. Offer to answer any questions the patient may have after reading the brochure. 4. Give the patient a Release of Personal and Medical Information Form and briefly explain

Total Recall program. Patients are more likely to sign a release form with an explanation. Note: A signed release form is valid for 4 years — if you have a system for coding files, you will not need to have every patient sign a release at every visit.

5. Accept signed Release form. Provide yellow copy of Release form to patient.

During the Exam: There are one or more possible opportunities for the Dr. to communicate the importance of regular eye exams

At the beginning of the exam, the Dr. reinforces behavior of a patient who has returned in 12-14 mos. and reminds those who have health conditions - i.e., Diabetes, or family medical history of health

conditions, why regular eye exams are important.

During the exam, Dr, indicates that small changes in vision are not readily apparent to patients, but nonetheless affect comfort and quality of life.

At the end of the exam based on his/her evaluation, the Dr. recommends a pre-appointment for next year to the patient. Note: Patients take a Dr.'s recommendation seriously!

During Checkout: Office Staff checks the patient out including eyewear purchases and pre

appoints them for their next appointments.

1. Check the patient out using the Appointment Book. Note: If a patient is not checked in and out of the Appointment Book, it will appear that they were a no “no show" and may subsequently receive a call or email to reschedule their appt.

2. Reinforce Dr.'s recommendation for pre-appointing with the patient. As a starting point, offer the patient an appointment on the same day and time next year. Reassure the patient that they will receive a reminder and if they end up with a conflict, they will be able to reschedule. Discussing the pre-appointment with a patient is important.

3. Pre-appoint the patient for their next appointment in the Appointment Book. Patients can only be pre-appointed if they have a signed Release of Personal and Medical Information Form on file.

4. Provide patient with appointment card indicating the date and time of pre-appointment. Encourage your patient to save the card in a calendar or on the refrigerator and welcome them to call the office to reschedule if they know of a conflict in advance. It is important that your patient knows when their next appointment is set prior to leaving your office.

5. File white copy of Release form in patient file.

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Scheduled Appt Confirmed Appt Checked In Checked Out Pre-Appt . Online Appt

See Quick Reference on Reverse

Quick Reference

Making an Appointment The blue cells on the schedule indicate the times the optometrist is available for appointments. The white cells are used for work-in appointments. Click the (a) (exam appointments) or (ck) (check or test appointment) on an open time cell to create a new appointment. Enter patient's last name, Click Search

If previous patient, click name from Patient List If not, click back button Required fields: First & Last name, DOB, phone number, email address, and Appointment Type. Optional: any visit explanation Click Next (If this is a new patient, you are done) For existing patients, if rescheduling a future appt, click reschedule; if not, click finished

Moving a Patient from Pre-Appointment to Scheduled Appointment Page Click Search. Enter last name or phone number and first name or DOB to narrow search. Click Search Click update next to patient's pre-appointment, then click cut, ok (pre-appt. info will show on clipboard at top right of screen), navigate calendar to new day/time on Scheduled Appointments, click (p)

Rescheduling an Appointment Click on patient's name Click Cut Click OK to add to your clipboard (top right on screen) Click on (p) on the rescheduled day/time

Checking a Patient In Click on patient appointment - Click Check In — appointment turns purple

Checking a Patient Out Click on appointment that has checked in - Click Check Out Complete required fields. Click yes to pre-appointment (for exams only), then Ok (pre-appt. info will show on clipboard at top right of screen), the calendar navigates to Unconfirmed Pre-appointments page and 53 weeks ahead. Click the (p) on agreed upon date/time. Pre-appointment appears in pink. Click Home to return to schedule and today's date. Checked out appointment is now blue.

Accessing Reports Click Reports button The Schedule Report (default) may be printed out by time, by Optometrist, and alphabetically by patient name (Order). Additional Reports by store, individual optometrist and by date range: Same Day, No Show, Cancellation, Pre-Appointment, Completed, Appointment Type Enter parameters; click Refresh to view updated report Click Print to print report

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Finding or Updating Patient Information Click Search Enter by last name only, or add first name, DOB, or phone to narrow search. Click Search Click patient's name or click on update next to patient's appointment, then click update next to patient's name. Buttons on the bottom of the screen link to: Contacts, Insurance and Appointments (shows all past and future appointments).

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Section 6: CONTACT LENS PROCEDURES & FORMS

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FEDERAL TRADE COMMISSION (FTC) CONTACT LENS RULE

The Federal Trade Commission (FTC) Contact Lens Rule implements the Fairness to Contact Lens

Consumers Act (FCLCA). The Contact Lens Rule closely adheres to the FCLCA, as is legally required for all rules authorized by a controlling statute. What follows is a comprehensive explanation of the

Contact Lens Rule in a user-friendly question-and-answer format. General Issues: 1. What is the official name of the FTC rule? The FTC rule is officially called the "Contact Lens Rule." Its

official citation is 16 CFR 315. It covers eleven sections from 16 CFR 315.1 to 16 CFR 315.11.

2. Does the rule require me to release a contact lens prescription to a patient? YES! You must give the patient a copy of the patient's contact lens prescription upon the completion of the fitting of the contact lens. You must do so automatically. No request from the patient is necessary.

3. Can I require a patient to pay for an examination and fitting before releasing the patient's contact lens prescription to them? Yes! However, there are required circumstances that you must adhere to in order to do so. First, you can only require payment

for the current examination and fitting fees, not for other past-due balances owed. Second, you must require that all your patients pay you up front — even those who do not need any

ophthalmic goods. Third, the patient's providing proof of insurance coverage is sufficient to constitute a payment. However, the FTC has expressly stated that the patient must provide proof of a current (in-force) insurance plan that covers the patient, and is an insurance plan accepted by the provider. The patient need not prove that the insurance will specifically pay the claim (for example, the insurance may be perfectly valid, but have a deductible provision). Proof of current insurance coverage for the particular patient in a plan accepted by the optometrist is all the patient need provide.

4. Must I verify a contact lens prescription upon the request of a contact lens seller? YES! Failure to

verify the request will permit the seller to sell the lens after eight (8) business hours have elapsed. The seller must send, and you must receive, a proper and complete verification request in order to start the eight (8) hour clock running. The verification request must contain all of the following items to be proper and complete: 1) the patient's full name and address; 2) the contact lens power, manufacturer, base curve or appropriate designation, and diameter when appropriate; 3) the quantity of lenses ordered; 4) the date of the patient request; 5) the date and time of the verification request; 6) the name of the contact person at the seller's company, including facsimile and telephone numbers; and 7) if the seller opts to include Saturdays as business hours, a clear statement of the prescriber's regular Saturday business hours.

Counting Business Hours:

5. How is a business hour defined in the new Contact Lens Rule and how does that affect me as an optometrist? A business hour is an hour between 9:00 a.m. and 5:00 p.m. Monday through Friday, excluding federal holidays. Under the Contact Lens Rule, you have eight (8) business hours in which to respond to a contact lens seller's request for verification of a contact lens prescription.

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For example, if you receive a verification request at 9:00 a.m. on a Monday, you must verify by 5:00 p.m. that same day, or the seller can sell the contact lens at 5:01 p.m. that same day. Another example — if you receive a verification request at 2:00p.m. on a Sunday, you must verify by 5:00 p.m. on Monday. Another example — if you receive a verification request at 7:00 p.m. on Wednesday, you must verify by 5:00 p.m. on Thursday. Another example — if you receive a verification request at 3:00 p.m. on Tuesday, you must verify by 3:00 p.m. on Wednesday.

6. What about Saturdays - can they be counted as business hours under the new Contact Lens Rule? YES! Saturdays can be counted as business hours at the option of the contact lens seller. In order for the seller to count Saturdays as business hours, the seller has to have actual knowledge of the hours that your office is open on Saturday. The seller must include in the verification request a clear statement of your regular Saturday business hours in order to count those hours as business hours. The seller must also maintain a record for not less than three years, available for inspection by the FTC, of your regular Saturday business hours and the basis for the seller's actual knowledge of those hours. If Saturdays are counted as business hours, then those actual Saturday hours must be included in the overall eight (8) hour calculation. For example - you have Saturday business hours from 11:00 a.m. to 3:00 p.m., and the seller notes in a verification request that you receive on Friday at 12:00 noon your Saturday hours - you then must verify by 2:00 p.m. on Saturday. If you had no Saturday business hours or the seller did not opt to list those Saturday hours in the verification request, then you would not have to verify until 12:00 noon on Monday in this example.

7. What time zone is used to calculate business hours? Only the prescriber's time zone is used to calculate business hours. For example, if a verification request is received by an optometrist at 9:00 a.m. Central Standard Time, the eight (8) business hours are calculated from that time, not the 10:00 a.m. Eastern Standard Time or the 7:00 a.m. Pacific Standard Time from where the seller may have sent the request.

Conduct of Sellers and Prescribers: 8. Can one contact lens seller keep sending me the same verification request over and over again?

NO! The FTC has expressly stated that the Contact Lens Rule only permits a single contact lens seller to send the exact same verification request for the same patient once. A seller can send a different verification request for the same patient (including one that alters required information or supplies missing required information from a previous request), but cannot send exactly the same request for the same prescription for the same patient more than once.

9. Can one contact lens seller keep sending me the same verification request over and over again? NO! The FTC has expressly stated that the Contact Lens Rule only permits a single contact lens seller to send the exact same verification request for the same patient once. A seller can send a different verification request for the same patient (including one that alters required information or supplies missing required information from a previous request), but cannot send exactly the same request for the same prescription for the same patient more than once.

10. Can multiple contact lens sellers send me the same verification request? YES! As long as different contact lens sellers send the verification request, that is permitted under the Contact Lens Rule. You would have to respond to each such verification request.

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11. What contact lenses are covered by the Contact Lens Rule? Any contact lens for which either State or Federal law requires a prescription is covered by the Contact Lens Rule. There are no exceptions for specialty lenses or rigid gas permeable contact lenses. The Contact Lens Rule does not cover Plano cosmetic lenses, unless State law requires a prescription for such Plano cosmetic lenses. If Federal law changes to require a prescription for Plano cosmetic lenses, then the Contact Lens Rule will cover them. However, current Federal law does not require a prescription for such Plano cosmetic lenses and very few State laws do either.

12. Must I verify as accurate a one-year prescription for a 12-month supply of contact lenses that is

submitted to me by a contact lens seller in the 11th month of the validity of the prescription in other words, the prescription would expire in one month, but the patient is seeking a full 12 month's supply of lenses)? NO! The FTC has expressly stated that you can notify the contact lens seller that the prescription is inaccurate based on the excessive quantity of lenses being ordered. The FTC has interpreted the Contact Lens Rule as recognizing that the purpose of requiring that the verification request state the quantity of lenses being ordered is precisely to prevent this type of overfilling that would evade the proper expiration date of the prescription. Therefore, in our example, the optometrist should notify the seller that the prescription is inaccurate and correct the quantity to only one month's supply of contact lenses.

13. May I place the quantity of lenses and refills on the prescription itself? YES! You are not required by the Contact

14. Lens Rule to place this information on the actual prescription, but you have the option of doing so (and you must do so if the State law requires it). However, you may not use this as a means of artificially shortening the expiration date of the prescription. You must ensure that the quantity you list; would be sufficient to last through the expiration date of the prescription.

15. What must be included on a contact lens prescription under the Contact Lens Rule? The contact lens prescription must include all the required information under both your State law and Federal law, including, but not limited to, the following: 1) the name of the patient; 2) the date of the examination; 3) the issue date and expiration date of the prescription; 4) the name, postal address, telephone number, and facsimile telephone number of the prescriber; 5) the power, material, or manufacturer or both of the prescribed contact lens; 6) the base curve or appropriate designation of the prescribed contact lens; 7) the diameter, when appropriate, of the prescribed contact lens; and 8) in the case of a private label contact lens, the name of the manufacturer, trade name of the private label brand, and, if applicable, trade name of equivalent brand name.

16. What is the "issue date" of a prescription and what is the importance of this issue date? The issue date of the prescription is the date on which the patient receives a copy of the prescription at the completion of a contact lens fitting. The FTC has expressly stated that there is only one issue date for any prescription, and the patient cannot alter the issue date by requesting additional copies of the prescription after the issue date. The issue date is important because that is the date from which the expiration period of the prescription is legally measured.

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17. What is a private label contact lens and why should this concern me as an optometrist? A private label contact lens is any contact lens sold under the label of a seller where the lenses are identical to lenses made by the same manufacturer but sold under the labels of other sellers. When you prescribe a private label contact lens you must include on the prescription the name of the manufacturer, the trade name of the private label brand, and, if applicable, the trade name of equivalent brand name. Also, a contact lens seller is authorized under the Contact Lens Rule to substitute for a private label brand an identical lens manufactured by the same manufacturer but sold under a different label. This is the only instance where a contact lens seller may substitute for the literal lens listed in the prescription.

18. Can I require a patient to pay any additional amount for releasing a copy of the patient's contact lens prescription to the patient or for verifying a patient's contact lens prescription? NO! It is prohibited to charge the patient any fee for releasing the copy of the patient's prescription to the patient, or for verifying the prescription.

19. Can I require a patient to sign any kind of waiver or release as a condition of releasing a copy of the patient's contact lens prescription to the patient or for verifying a patient's contact lens prescription? NO! It is prohibited to have the patient sign any release or waiver for either releasing the copy of the patient's prescription to the patient, or for verifying the prescription.

20. Can I require a patient to purchase lenses from me or another person as a condition for releasing copy of the patient's contact lens prescription to the patient or for verifying a patient's contact lens prescription? NO! It is prohibited to require the patient to purchase any lenses from yourself or another person as a condition for releasing the copy of the patient's prescription to the patient, or for verifying the prescription. However, as noted earlier, where specialty lenses are involved, you may charge the patient for the cost of the specialty lens needed to carry out the normal fitting process.

21. Am I allowed to offer patients a package deal combining eye care services, lenses and

replacement lenses? Yes! The FTC has expressly stated that optometrists can market package deals of bundled services to patients, provided that the patient is always given the option to purchase the contact lenses elsewhere from whomever they wish.

22. Can a contact lens seller sell a contact lens without having any prescription? NO! There are serious penalties of up to $11,000 per violation for a contact lens seller violating any provisions of the FCLCA. The contact lens seller must either have the contact lens prescription delivered to them directly by the patient or prescriber, transmitted to them by facsimile transmission by the patient or prescriber, or transmitted to them by a digitally imaged e-mail from the patient or prescriber — or the contact lens seller must verify the prescription by direct communication to the prescriber.

23. Once I receive a verification request from a contact lens seller, can I just ignore that request and let eight (8) hours elapse? YES! If the prescription is correct in all respects and is not expired, but NO if the prescription is incorrect or is expired. Why are there two different answers to this question? The first "yes" part of the answer is based on the fact that the seller will be able to sell the lenses after eight (8) hours elapse and you make no response, which is not going to cause either you or the patient any problem if the prescription is completely correct and is not expired.

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24. However, if the prescription is incorrect or expired, it would be a very dangerous mistake to fail to respond and it could put your license to practice optometry at risk and subject you to serious malpractice liability. That is why the second part of the answer is "no." While the Contact Lens Rule does not legally force you to respond to any verification request before eight (8) hours elapses, the deliberate, knowing failure to respond to a verification request that you know to be incorrect, and that may ultimately cause harm to your patient if incorrect lenses are sold or an incorrect quantity of lenses is sold, would leave you defenseless to a malpractice lawsuit or a charge of professional misconduct by your state licensing authority. You do not want to put yourself in this position. Plus, if you correctly verify the prescription, Section 7 of the FCLCA expressly does not impose any liability on you for any ophthalmic goods and services dispensed by the seller pursuant to your correctly verified prescription. It would be nothing short of foolhardy to throw away this opportunity to immunize yourself from liability. Finally, beware of being too complacent about not responding to verification requests for completely correct, unexpired prescriptions, as you do not want to have office procedures in place that could let an incorrect or expired prescription slip through and potentially put you at risk of professional discipline or malpractice actions.

25. What constitutes verification of a prescription? There are three things that constitute verification of a prescription - 1) you confirm the prescription is accurate by direct communication with the seller; 2) you inform the seller through direct communication that the prescription is inaccurate; or 3) you fail to respond at all within eight (8) business hours after receiving the verification request (the seller is obligated to provide a reasonable opportunity for you to communicate with the seller concerning the verification request within those eight (8) business hours).

26. How do I respond to an expired prescription on a verification request? You inform the contact lens seller that the prescription is expired. If you do not know the correct new prescription (for example, you have not examined the patient to determine the new prescription), then you are not obligated under the Contact Lens Rule to provide any other information to the contact lens seller on an expired prescription. If you do know the correct new prescription, you should advise the contact lens seller of the correct new prescription.

27. How do I respond to an inaccurate prescription on a verification request? You advise the contact lens seller that the prescription is inaccurate and you must specify the basis for the inaccuracy and you must correct the inaccuracy.

28. What does direct communication mean between a seller and a prescriber? Direct communication means a completed communication by telephone, facsimile, or electronic mail. If by telephone, it means reaching and speaking with the intended person, or leaving a voice message on the answering machine of the intended recipient. If by facsimile or electronic mail, it means that the intended recipient actually receive the message sent. However, the FTC has expressly stated that a facsimile confirmation is usually sufficient proof that the facsimile transmission was received, and confirmation that an e-mail was sent is usually sufficient proof that the e-mail was received. Consequently, sellers will begin counting the eight (8) business hours from the time they obtain these facsimile or e-mail confirmations.

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29. May a contact lens seller alter the prescription in any way? NO! The contact lens seller is prohibited from altering the prescriber's prescription in any respect. As discussed earlier, only in the limited case of a private label contact lens for which the same manufacturer makes the identical lens, but sells the lens under another brand name, may the seller substitute the identical lens from that same manufacturer under that other brand name. In effect, this is not a true alteration of the prescription, but is designed to prevent the use of private label lenses to frustrate a patient purchasing lenses from other than the optometrist.

Expiration Dates and Recordkeeping Requirements: 30. Are sellers required to keep records of their verification transactions? YES! Sellers must keep

extensive records of verification transaction for no less than three (3) years, and must permit the FTC access to inspect such records. Such records must consist of: I )for prescriptions presented to the

seller by the patient or the prescriber: the prescription itself or the facsimile version, or the digitally imaged e-mail version; 2) for verification requests: a copy of the verification request, including all required information on the request, and confirmation of the completed transmission of the request

to the prescriber, including a record of the date and time the request was made; 3) for telephone

communications: a telephone log for communications made by telephone showing the verification

information provided over the phone, the date and time the request was made, an indication of how

the call was completed, and the names of all the persons who participated in the call; 4) for communications from the prescriber: how the communication was received, a copy of the

communication if by e-mail or facsimile and a record of the date and time the communication was received; and if by telephone: a log describing the information communicated, the date and time the

information was received, and the names of the persons who participated in the call. Sellers also must, as discussed earlier, keep records proving the Saturday business hours of prescribers with

whom they count Saturday business hours. Prescribers are not subject to any recordkeeping

requirements under the Contact Lens Rule (but see question 30 below). However, all prescribers

should keep accurate patient records as a matter of normal optometric practice.

31. How do expiration dates work for contact lens prescriptions under the Contact Lens Rule? The

answer to this depends on the state in which you write the contact lens prescription and involves three scenarios as follows: 1) if your state has no contact lens prescription expiration date law of its own, then the FCLCA imposes a one year expiration date; or 2) if your state has a contact lens prescription expiration date law that is one year or longer, then your state law controls the expiration date; or 3) if your state has a contact lens prescription expiration date law that is less than one year, then the FCLCA overrides your state law and imposes a one year expiration date.

32. May I write a contact lens prescription expiration date that is less than one year under any

circumstances? YES! If in your considered medical judgment, the specific health needs of a particular patient require a less than one year contact lens prescription expiration date, then you may write a prescription with such a shorter expiration date. However, you must then also do three things: 1) you must document in the patient's medical record the specific reasons for your medical judgment in sufficient detail to allow for review by another qualified professional in the field; 2) you must maintain this documentation for no less than. three (3) years and have it available to the FTC for inspection; and 3) the shorter expiration date can never be less than the time period you recommend for a medically necessary reexamination of the patient.

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Miscellaneous Items:

33. Does the Contact Lens Rule impose any advertising restrictions on sellers? YES! It is prohibited for

any person who manufactures, processes, assembles, sells, offers for sale, or distributes any contact lenses to represent, whether by advertising, making a sales presentation, or any other means, that contact lenses may be obtained without a prescription.

34. How will the Contact Lens Rule be enforced? The FTC has enforcement authority over the Contact Lens Rule. Any violation of the rule by either a seller or a prescriber is treated as a violation of

Section 18 of the FTC Act regarding unfair or deceptive acts or practices, and can subject the

violator to penalties up to $11,000 per violation. The FTC has broad enforcement powers under the FTC Act and is not an agency to be trifled with.

35. Does the Contact Lens Rule preempt state laws and rules? YES! But only under certain

circumstances! Like all federal laws and rules, the Contact Lens Rule would preempt any state law or

rule that directly contradicted a provision of the Contact Lens Rule. In addition, the Contact Lens Rule specifically preempts any state law or rule that requires active verification of a contact lens

prescription that restricts contact lens prescription release, that establishes a prescription expiration date of less than one year, or that would be inconsistent with the FCLCA or the Contact

Lens Rule to the extent of the inconsistency.

36. Do the patient privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) interfere with my complying with the contact lens prescription verification

requirements of the Contact Lens Rule? NO! The FTC has expressly stated that HIPAA does not

conflict with or override the obligations of the Contact Lens Rule. That is entirely consistent with

the official opinion of the Office of Civil Rights (OCR) of the United States Department of Health

and Human Services, which enforces the HIPAA privacy provisions. OCR has already ruled that the verification of a contact lens prescription to a contact lens seller is a protected, permissible transmission of health care information that does not require any separate written authorization

from the patient.

Reporting Seller Violations to the FTC:

37. Should I report seller violations of the Contact Lens Rule to the FTC? The Contact Lens Rule will only work to help patients and optometrists if both sellers and prescribers obey the rule and the FTC

properly enforces the rule. Instances of seller violations should be well documented by the prescriber

and immediately reported to the FTC with a request for FTC investigation and action. You can file the violation report with the FTC electronically through the AOA Web site at www.aoa.org or you can

directly file it with the FTC via their Web site www.ftc.gov by clicking on the "File A Complaint" option

there.

http://www.aoa.org/

http://www.ftc.gov/

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CONTACT LENS FOLLOW UP AND RELEASE GUIDELINES EYEXAM of California members have covered contact lens follow-up visits at no charge for the first 6 months after contact lenses are dispensed. After the 6 months, a contact lens follow-up fee will be charged per doctor discretion. Contact lens selection is based on doctor-patient communication and recommendations of the doctor based on lifestyle, use, age, ocular health, etc. Release of trials, follow-ups, and finalization of contact lens prescription is up to the doctor’s discretion. If a patient’s contact lens parameters, brand or modality has not changed, or if a patient’s fit is successful in-office, a contact lens prescription released same day is appropriate. Selection of contacts and fitting process can only be conducted and completed with trials the doctor can personally verify are valid. Suggested guidelines below are for all soft spheres, toric and multifocal fittings: First time contact lens user fitting: Initiate insertion & removal training; dispense trials, follow-up within 1-2 weeks. Use the contact lens new wearer form and provide copy to patient and document fitting and wear schedule on yellow contact lens form in chart. Schedule second follow-up if needed. Finalize & release prescription when fitting is completed and return for annual contact lens exam. Previous contact lens user fitting: Dispense trials, schedule 1-2 week follow-up if needed. Finalize & release prescription when fitting is completed and return for annual contact lens exam. *For any previous contact lens user with signs of contact lens misuse, abuse or over-wear (i.e. history of red eyes, infections, corneal neovascularization, or difficulty with insertion and removal), a follow-up should be scheduled to evaluate the new fit. Rigid Gas Permeable and other specialty fitting: Order lenses by consultation with contact lens manufacturer or from previous parameters if same, schedule follow-up if needed when lenses arrive to evaluate RGP fit in-office. Dispense lenses and follow-up in 1-2 weeks for adaptation. Finalize & release prescription on completion of fit and return; for annual contact lens exam. Cosmetic Color Contact Lenses: Color contact lenses either as plano or with correction are regulated medical devices under the U.S. Food and Drug Administration and require a valid prescription for purchase. Contact lenses should be fit according to the same guidelines and prescription release as clear lenses. Please refer to the policy taken from the California Board of Optometry laws and regulations section below:

§2541.2. RELEASE OF CONTACT LENS PRESCRIPTION TO PATIENT; EXPIRATION DATE OF PRESCRIPTION;

VIOLATION OF SECTION UNPROFESSIONAL CONDUCT

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(a) The expiration date of a contact lens prescription shall not be less than one to two years from the

date of issuance, unless the patient's history or current circumstances establish a reasonable probability

of changes in the patient's vision of sufficient magnitude to necessitate reexamination earlier than one

year, or the presence or probability of visual abnormalities related to ocular or systemic disease indicate

the need form reexamination of the patient earlier than one year. If the expiration date of a prescription

is less than one year, the health-related reasons for the limitation shall be documented in the patient's

medical record. In no circumstances shall the prescription expiration date be less than the period of time

recommended by the prescriber for reexamination of the patient. (2) For the purposes of this

subdivision, the date of issuance is the date the patient receives a copy of the prescription. (3)

Establishing an expiration date that is not consistent with this section shall be regarded as

unprofessional conduct by the board that issued the prescriber's license to practice.

(b) Upon completion of the eye examination or, if applicable, the contact lens fitting process for a

patient as described in subdivision (f), a prescriber or a registered dispensing optician shall provide the

patient with a copy of the patient's contact lens prescription signed by the prescriber, unless the

prescription meets the standards set forth in subdivision (c).

(c) A prescriber shall retain professional discretion regarding the release of the contact lens prescription

for patients who wear the following types of contact lenses: (1) Rigid gas permeables. (2) Bitoric gas

permeables. (3) Bifocal gas permeables. (4) Keratoconus lenses. (5) Custom designed lenses that are

manufactured for an individual patient and are not mass produced.

Sources:

1. California State Board of Optometry: Optometry Laws and Regulations, Revised 2015, pages 76-77.

http://www.optometry.ca.gov/lawsregs/laws.pdf

2. http://www.optometry.ca.gov/formspubs/cosmetic_contacts.pdf

http://www.optometry.ca.gov/lawsregs/laws.pdf

http://www.optometry.ca.gov/formspubs/cosmetic_contacts.pdf

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Online Contact Lens Seller Form

Date:

Patient Name: ________________________________________________________ Patient Address: ______________________________________________________ Record #

Fax # : Contact Person:

Sphere Cyl Axis Add BC Dia Brand

OD

OS

Expiration Date:

The prescription is (mark one):

Accurate as described.

Incorrect for the right eye / left eye / both

eyes (circle one); Correct parameters are:

Expired. An eye exam is necessary to re-evaluate vision and eye

health.

Unable to be verified. We have not seen this patient at this office.

EYEXAM of California (use store stamp)

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Section 7: EMERGENCY PROCEDURES & PHYSICIAN REFERRAL

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I. Ocular Emergency – a condition that can cause a sudden loss of, or decrease in a person’s vision

that could lead to a permanent condition. 2

Ocular Presentations can be sorted into 4 Classifications A. Emergency—within 1-2 hours

B. Urgent—within 24 hours

C. Priority—within a week

D. Routine—Mutually convenient time within a month

Examples of True Ocular Emergencies: MUST BE SEEN OR REFERRED IMMEDIATELY A. Sudden loss of vision, complete or partial, in one or both eyes or with affiliated

neurological symptoms

B. Sudden vision loss in one quadrant or side of both eyes, even without neurological

symptoms, but with weakness or tingling in an extremity or side of the body, must be

evaluated as an emergency

C. Sudden increase in ocular pain

D. Any significant ocular injury or chemical burns

E. The sudden onset of TRUE double vision. (Covering either eye will eliminate the second

image)

F. Sudden bulging of the eye with or without loss of motion of the eye

G. Bleeding in or around the eye that is affiliated with pain or trauma

II. Emergency Telephone Triage

A. Fill out the Emergency Telephone Triage Form (see Phone Triage Form Section 7)

B. Pull records and consult with the doctor. If there is any question regarding a patient’s

symptom, condition or need for referral, consult the doctor. Always err on the side of

caution.

C. Document outcome of phone call, such as an appointment scheduled or referred.

D. Place the triage form in the chart, if applicable.

E. Start a file for the patient if the caller is a new patient.

3 Things to always remember A. Everyone must be trained in emergencies!...Training

B. Must know who to contact…too late to look it up…post it

C. There is NO SUCH THING AS A ROUTINE PATIENT until the exam is complete. 1

III. Emergency Telephone Triage Management of Patient Inquires

A. Vision Loss, partial or complete, transient or persisting

i. The sudden onset of complete visual loss in one or both eyes is a serious emergency

and must be evaluated immediately by an optometrist, ophthalmologist, urgent

care, or emergency room.

ii. Advise the patient to breathe in and out of a paper bag for several minutes while

covering both nose and mouth to see whether vision returns while en route to be

GUIDELINES FOR THE MANAGEMENT OF PATIENT INQUIRIES AND OCULAR EMERGENCIES

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evaluated. The sudden onset of an altitudinal vision loss in one eye should be

treated the same way.

iii. Vision loss which is associated with pain, redness, white spots over the cornea,

weakness, tingling, numbness, or other unusual sensations in any extremity of part

of the body, severe headaches, dizziness, vertigo, buzzing or ringing sounds in the

ears, nausea or vomiting, must be seen on an immediately by an ophthalmologist or

an emergency room

iv. Sudden vision loss in one quadrant or side of both eyes, even without neurological

symptoms, but with symptoms such as weakness or tingling in an extremity or side

of the body, can be an indication of a stroke and must be evaluated as an

emergency.

v. Transient loss of all or some of the vision in one or both eyes lasting anywhere from

seconds to a half hour should be evaluated within 24 hours by an ophthalmologist

or emergency room.

vi. The painless, progressive loss of vision over months or more can be evaluated at a

mutually convenient time.

vii. Differential diagnosis:

i. Painless vision loss: Central Retinal Artery Occlusion, Central Retinal Vein

Occlusion, Giant Cell Arteritis, and Vitreous Hemorrhage

ii. Painful vision loss: Acute Angle Closure Glaucoma and Optic Neuritis

iii. Painless, progressive vision loss: refractive error change, cataracts, dry age-

related macular degeneration or age

B. Injuries

i. Global rupture – if the injury is associated with moderate to severe pain, decrease in

vision, hyphema, loss of anterior chamber depth or deviation of pupil toward

laceration, the patient should be seen at the ER immediately.

ii. Blunt Trauma – If the injury is associated with persistent pain or blurred vision, the

patient should be seen immediately by an ophthalmologist or in an emergency room

to rule out blowout or orbital floor rupture, retinal detachment, choroidal rupture

or traumatic optic neuropathy.

iii. Chemical Injuries -- The patient should be advised to extensively flush the eye with

sterile saline immediately for about fifteen minutes. The patient should then

proceed to an optometrist, ophthalmologist or urgent care to be further evaluated.

iv. Sharp Injuries: The patient should be evaluated immediately, even if there is no

significant persisting pain or loss of vision at the time of the call. If there is pain or

loss of vision, the patient should be evaluated by an ophthalmologist or in an

emergency room. Advise the patient to protect eye, avoid straining and any

pressure on eye.

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C. Double Vision

i. True double vision consists of distinct second images. The second image can be

displaced vertically, horizontally, or obliquely, in which covering either eye WILL

eliminate the second image. Sudden onset of such double vision should be

evaluated by an ophthalmologist, neurologist or in the emergency room.

ii. Shadows, ghosting or double vision through one individual eye does NOT constitute

true double vision.

D. Flashes

i. The patient should be seen immediately if the flashes are associated with sudden

onset of many new floaters, shadows, or curtains coming over the vision, or if the

patient has experienced recent trauma.

ii. Patterned flashes of lights, like a kaleidoscope or lightning bolts, or zigzag designs

especially if associated with subsequent headache can represents symptoms of

migraine, but the patient should be seen within 24 hours to rule out a retinal

detachment.

E. Floaters

i. Large inkblot-like floaters, a sudden “snow storm” of floaters, and associated

flashes, visual changes, or the appearance of large shadows or curtains developing

over the vision of the affected eye, even though central vision may remain clear,

should be seen within 24 hours by an optometrist, ophthalmologist or the ER.

ii. The sudden onset of a few new or different types of floaters which do not impair

vision, are not associated with flashes, curtains, or large shadows, and be evaluated

within several days with a dilated eve exam.

F. Headaches

i. If there is genuine significant pain above the eye in the brow, particularly if

associated with a change in vision, halos around lights, and redness of the eyes,

these symptoms may indicate acute closure glaucoma and must be seen

immediately by an optometrist, ophthalmologist or the ER.

ii. Headaches which are present upon awakening in the morning, or which may

awaken patients during the night, or associated with nausea or vomiting, weakness

in an extremity, tingling sensations, and visual auras such as flashing zigzag lights or

kaleidoscopic images, can represent neurological problems and should be seen by a

neurologist or internist as soon as possible.

iii. Headaches with neck pain and fever should also be seen at the ER immediately

because it could be sign of meningitis.

iv. Other headaches specifically related to the uses of the eyes, such as intensifying

later in the day, after reading or concentrated eye use, constitute eye strain and can

be seen on a routine visit.

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G. Swelling of the Lids, Conjunctiva, or Eye

i. Protrusion of the eye itself of sudden onset should be evaluated immediately,

particularly if associated with some change in vision, double vision, and restriction

of motion of the eye, pain, or redness.

ii. If there is truly significant swelling, redness, pain, or discharge the patient should be

seen within 24hours.

iii. Swelling of the conjunctiva, which will appear to the patient like a “blister” on the

eye, or a clear bubble, should be seen within 24hours.

iv. If the protrusion of the eye is slowly progressive, it can be evaluated within several

days by an ophthalmologist.

v. If swelling of the lids is associated with itching, depending on the severity, the

patients can be seen within several days.

vi. If the lid swelling is associated with the use of contact lenses, nonprescription eye

drops or solutions, the patient should be advised to stop all drops and solutions

until the patient can be evaluated at a

H. Discharge

i. Thick discharge, crusting, significant mattering, but without pain or vision change,

should be seen within one or two days.

ii. Watery discharge or tearing associated with itching minimal redness, but no pain and visual loss, should be seen within several days.

I. Foreign Body Sensation

i. If there is a loss of vision or significant associated pain, the patients should be seen as a true emergency and be seen now or referred.

ii. If the sensation is associated with contact lens wear and is relieved by removal of

the contact lens, advise the patient to remove the lens and be seen at a mutually

convenient time. If their symptoms worsen then the patient should be seen within

24 hours to rule out an ulcer.

J. Halos around light

i. Seeing halos around lights may indicate acute glaucoma. If there is associated

reduction in vision, pain, and redness of the eye, the patient should be seen

immediately.

ii. The chronic appearance of halos or blurring of vision, without any pain or real

change in vision or redness, might relate to refractive error, or cataracts and can be

evaluated within several days.

K. Itching

i. If the itching is associated with the use of contact lens, contact lens solutions or

non-prescription eye drops, patient should be advised to discontinue the use of any

possible offending agents. The patient can schedule at a mutually convenient time.

ii. If the patient does not know the source of the itching, the patient can schedule a

routine appointment

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L. Lid Masses/Bumps

i. Any rapidly progressive mass, particularly if discharging and associated with

surrounding swelling of the eyelid should be evaluated on an emergency basis.

ii. Chronic lumps, bumps or other masses of the eyelid may represent benign cysts, or

malignant tumors. They should be evaluated as soon as possible at a mutually

convenient time.

iii. Differential diagnosis: hordeolum, chalazion, basil cell carcinoma, squamous cell

carcinoma and sebaceous carcinoma

M. Light Sensitivity/Photophobia

i. The sudden onset of severe light sensitivity should be evaluated on an emergency

basis, particularly if associated with pain, redness, or change in vision.

ii. If light sensitivity develops with the use of contact lenses and other symptoms of

discharge, pain or blurred vision exists, the lenses should be removed, not

reinserted and the patient should be seen within 24hours.

iii. Slowly increasing light sensitivity over a period of months or more, without

significant changes in vision can be evaluated at a mutually convenient time.

N. Pain

i. Pain in and about the eye, particularly in the brow region, as well as in the eye itself,

can indicate severe ocular disease.

ii. If the pain is associated with changes in vision, redness, and/or halos noted about

the lights, it may in fact represent a true emergency and the patient should be seen

immediately by an ophthalmologist or emergency room.

iii. Pain in the eye while a contact lens is being used should be seen as soon as possible.

The patient should be instructed to remove and not reinsert the contact lens.

iv. Pain in the eye persisting after the lens has been removed, especially if associated

with loss or change in vision, persisting redness of the eye, or discharge, should be

evaluated immediately.

v. If the pain is “eye strain”, obviously related to the use of the eyes a visually

demanding tasks, the patient can be evaluated at a mutually convenient time.

O. Ptosis (Drooping of the Eyelid)

i. The sudden onset of drooping of the eyelid, particularly if associated with double

vision, or unequal size of the pupils, the patient must be evaluated on an emergency

basis by an ophthalmologist or emergency room.

ii. Slowly progressive drooping of one or both eyelids without double vision can be

evaluated at a mutually convenient time.

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P. Inequality of the Pupils

i. Inequality of the pupils, if sudden, must be evaluated as an emergency, especially if

associated with double vision, drooping of the eyelid, headache, dizziness, weakness

of an extremity, tingling sensation anywhere, or areas of numbness.

ii. The patient should be advised to see an ophthalmologist or go to an emergency

room immediately.

iii. BE CERTAIN THE PATIENT HAS NOT RECENTLY TAKEN ANY EYE DROPS WHICH MIGHT

DILATE OR CONSTRICT ONE OR BOTH PUPILS.

Q. Redness of the Eyes

i. If redness is associated with pain, change in vision, or significant discharge, the

patient should be seen as soon as possible.

ii. If redness is associated with excessive tearing, pain, unusual light sensitivity or

change in vision in a contact lens user, the patient should be advised discontinue

contact lens wear and be seen within 24 hours.

iii. If there is thick discharge, mattering, crusting of the lashes, the patient should be

seen within one to two days.

iv. Simple redness with no other symptoms, no change in vision, no discharge, or no

pain can be seen at a mutually convenient time within a week.

v. If there is watery discharge plus itching, the appointment can be made at a mutually

convenient time.

vi. Redness associated with contact lens use, but no change in vision and no discharge,

can be evaluated when mutually convenient.

vii. Differential diagnosis: bacterial conjunctivitis, viral conjunctivitis, allergies, injury,

and toxic reaction

R. Tearing

i. If associated with pain, itching, discharge, change in vision, or painful swelling at the

inner corner of the eye, the patient should be seen within 24 hours.

ii. Excessive tearing that occurs with the use of contact lenses, particularly if it persists

after the contact lenses have been removed should be evaluated as soon as possible

at a mutually convenient time. The patient should be instructed not to continue

contact lens wear until evaluation.

iii. Excessive tearing alone can be evaluated by a doctor at a mutually convenient time.

iv. If associated with eye work or eyestrain, the patient should be seen for a complete

eye evaluation and refraction.

S. Blurred Vision

i. Vision may seem blurred with new spectacles for the first few days.

ii. If the vision is not as clear as expected within several days of use of the new glasses,

the patient should return a mutually convenient time for re-evaluation, preferably

with the doctor who prescribed the glasses.

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T. Change in vision

i. Severe loss of vision which persists upon removal of contact lens and despite use of

back up glasses should be seen within 24 hours.

ii. Sudden changes in vision associated with contact lens or glasses should be

evaluated within a day or two.

iii. Slowly progressive change in vision over time for glasses or contact lens patients can

be evaluated at a mutually convenient time.

U. Contact lens Related Complaints

i. Light Sensitivity, Pain, Redness, Tearing, Decreased Vision or White Spot on Cornea

after Contact lenses Use: Advise the patient to remove the contact lens and seek

evaluation as soon as possible and should be treated as an emergency.

ii. Contact lens Dislocation: Reassure the patient. Advise the patient to stop

manipulating the eye, put in lubricating drops if available and proceed to the

doctor’s office as soon as possible.

iii. Damaged Contact lenses: Instruct the patient not to place the damaged contact lens

in the eye and to make arrangements for replacement as soon as possible.

iv. Deposits on the Contact Lenses: Advise the patient to remove the contact lens and

to schedule an appointment as soon as possible.

References 1. WETSK_About_Ocular_Emergencies.pdf

2. www.aafp.org

3. www.aao.org

4. Bsmcpss.com

http://www.aafp.org/

http://www.aao.org/

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EMERGENCY TELEPHONE TRIAGE FORM

Date _____________ Time ______________ Staff ___________________________________

Patient Name________________________ (Established or New) DOB/Age ______________

Phone ________________________ (Cell/Work)

Chief complaint:

When did the problem begin? Have you ever had this problem before? When? What makes the problem worse? What alleviates the symptom(s)? Is there a loss of vision? Is the loss of vision partial or complete? Is the loss of vision in one eye or both? Did you experience injury? Blunt or Penetrating or Chemical? If blunt injury, pain on eye movement? Or is the eye bleeding (with a tissue)? If chemical injury, what chemical? Acid or base? How long ago was the incident? Is the patient a contact lens wearer?

Do you have any significant medical conditions (such as diabetes, high blood pressure, cancer or any other conditions)?

Are you taking any medications? If so, what kind?

Appointment Made: Date ______________________ Time _________________________ Referred: Where_____________________ When _________________________

Advice given:

EMERGENCY TELEPHONE TRIAGE DIRECTIONS: F. Fill out the Emergency Telephone Triage Form

G. Pull records and consult with the doctor

H. Document outcome of phone call, such as an appointment scheduled or referred

I. Place the triage form in the chart, if applicable

J. Start a file for the patient if the caller is a new patient

TRUE OCULAR EMERGENCIES: MUST BE SEEN OR REFERRED IMMEDIATELY H. Sudden loss of vision, complete or partial, in one or both eyes or with affiliated neurological

symptoms, weakness or tingling in an extremity or side of the body

I. Sudden increase in ocular pain

J. Any significant ocular injury or chemical burns

K. The sudden onset of TRUE double vision. (Covering either eye will eliminate the second image)

L. Sudden bulging of the eye with or without loss of motion of the eye

M. Bleeding in or around the eye that is affiliated with either trauma or pain

*If your doctor is not present, when in doubt, have them call 911 or refer to the nearest emergency

facility. The closest emergency facility to our location is ___________________________

at_________________________.

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BLOOD PRESSURE SCREENING AND REFERRAL GUIDELINE

Blood Pressure should be measured with a manual or automated sphygmomanometer on adults aged 18 years or older. Patients should be made aware that optometrists do not diagnose or treat systemic hypertension. This screening is performed to alert patients who may not be aware of this potentially serious problem that may also have effects and damage to the retina and optic nerve. Patients should be educated that they must be further evaluated, diagnosed and treated if necessary, by their primary care physician.

New: American Heart Association & American College of Cardiology Guidelines

• High blood pressure is now defined as readings of 130 mm Hg and higher for the systolic blood

pressure measurement, or readings of 80 and higher for the diastolic measurement. That is a

change from the old definition of 140/90 and higher, reflecting complications that can occur at

those lower numbers.

• In the first update to comprehensive U.S. guidelines on blood pressure detection and treatment

since 2003, the category of prehypertension is eliminated.

• By lowering the definition of high blood pressure, the guidelines recommend earlier intervention to

prevent further increases in blood pressure and the complications of hypertension.

• The new guidelines stress the importance of using proper technique to measure blood pressure.

Blood pressure levels should be based on an average of two to three readings on at least two

different occasions.

Key Steps for Proper BP Measurements:

To ensure accurate measurements, make sure the instrument you are using is properly calibrated.

Step 1: Properly prepare the patient.

Step 2: Use proper technique for BP measurements.

Step 3: Ask patient to sit quietly and remain still during measurements. Ensure that the BP cuff is at

heart level and using the correct cuff size; don’t take the measurement over clothes.

Step 4: Properly document accurate BP readings. Provide both measurements if two were taken 5

minutes apart.

Step 5: Provide BP readings to patient and document in chart.

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Classification of Blood Pressure as recognized by the American Heart Association and Referral Instructions per EYEXAM of California:

Category Systolic BP

(mmHg) Diastolic

BP (mmHg)

Referral Instructions

Normal <120 and <80 No Referral. Document and monitor in 1 year.

Elevated 120-129 and <80 Document in chart, educate patient and advise him/her to consult with their physician if they haven’t been seen within 1 year.

Hypertension Stage 1

130-139 or 80-89 Retake BP if needed. Document in chart, educate patient and advise him/her to consult with their physician if they haven’t been seen within 1 year.

Hypertension Stage 2

≥140 or ≥90 Retake BP. Document in chart, educate patient and write BP with time taken on Physician Referral form. Instruct patient to consult their physician within 3 weeks.

Hypertensive Crisis

A. Hypertensive Urgency ≥180 And/or >120 Wait at least 5 mins and retake BP or by end of exam. If second reading is just as high, advise patient to seek immediate medical help. Document in chart and on Physician Referral Form.

B. Hypertensive Emergency >180 + symptoms

And/or >120 + symptoms

Send patient immediately to an intensive care unit.

Document in chart and on Physician Referral Form.

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American Heart Association recommendations on Hypertensive Crisis: If a patient has a blood pressure reading of 180/120 or higher AND is experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, changes in vision or difficulty speaking, do not wait and call 911 immediately. Signs and Symptoms Potentially Related to Hypertension: 1. Severe headaches, especially with associated nausea or vomiting. 1. Angina or chest pain, back pain, shortness of breath, nosebleeds. 2. Any transient or persistent tingling, numbness, or weakness in hands, arms or legs. 3. Visual Disturbances e.g., classic amaurosis fugax, any bilateral or monocular visual

obscurations.

4. Hypertensive Retinopathy or papilledema. 5. Any other symptoms suggestive of transient ischemic attacks (TIA). 6. Claudication (i.e. cramping in the legs upon walking or exertion) 7. History of prior myocardial infarction (heart attack). 8. History of prior cerebrovascular accident (stroke). Note: Often Hypertension has no obvious signs or symptoms Any patient with Papilledema should be referred immediately to an Emergency Room, regardless of blood pressure readings.

Source: 1. http://professional.heart.org/idc/groups/ahamah-

public/@wcm/@sop/@smd/documents/downloadable/ucm_497372.pdf 2. https://healthmetrics.heart.org/2017-guideline-for-the-prevention-detection-evaluation-

and-management-of-high-blood-pressure-in-adults/

3. https://news.heart.org/nearly-half-u-s-adults-now-classified-high-blood-pressure-new-definitions/?utm_campaign=sciencenews17-18&utm_source=community-htn&utm_medium=phd-link&utm_content=phd11-13-17_htn-gl

FORMS & MEMOS: SEE SECTION 10 OR USE HYPERLINKS BELOW

Physician Referral Form

Physician Referral Follow-up Letter

http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497372.pdf

http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497372.pdf

https://healthmetrics.heart.org/2017-guideline-for-the-prevention-detection-evaluation-and-management-of-high-blood-pressure-in-adults/

https://healthmetrics.heart.org/2017-guideline-for-the-prevention-detection-evaluation-and-management-of-high-blood-pressure-in-adults/

https://news.heart.org/nearly-half-u-s-adults-now-classified-high-blood-pressure-new-definitions/?utm_campaign=sciencenews17-18&utm_source=community-htn&utm_medium=phd-link&utm_content=phd11-13-17_htn-gl



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Section 8: INSURANCE

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MEDICALLY NECESSARY CONTACT LENS CLAIM FORM

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MEDICALLY NECESSARY CONTACT LENS REIMBURSEMENT ASSIGNMENT PLANS

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MEDICALLY NECESSARY REIMBURSEMENT EyeMed

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REQUEST FOR LOW VISION SERVICE MATERIALS FORM

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Section 9: HIPAA, SUBPOENAS, PATIENT CHART DOCUMENTATION & STORAGE PROCEDURES FOR EMPLOYED OFFICES

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HIPAA – HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT What is HIPAA? The Health Insurance Portability and Accountability Act, or HIPAA, is a new government policy that requires businesses to protect a customer’s personal health information while providing products and services. This new policy took effect April 14, 2003.

This privacy policy includes among other things:

Includes guidelines to protect peoples’ rights to privacy and confidentiality regarding their protected health information, or PHI.

Provides people with increased rights to access their health information.

How does this affect Luxottica Retail?

HIPAA guidelines specify what information is considered confidential as well as how and under what conditions that information can be used and shared. These guidelines require that privacy standards be put in place to safeguard the personal data of the customer, which includes optical and optometric records and information.

To meet HIPAA regulations, Luxottica Retail is taking steps to ensure that our Associates and customers are informed about these new guidelines by:

o Establishing new policies and procedures for Luxottica Retail associates

o Creating a Notice of Privacy Practices (NPP) brochure to be given to our customer/patients informing them of our privacy policies related to the use and disclosure of health information.

o Providing HIPAA compliance training for all associates. HIPAA Training Information: Anyone who deals with health information is required to complete HIPAA training; this includes all EYEXAM of California, Inc., and Luxottica Retail associates. According to HIPAA guidelines, penalties for non-compliance can be severe, and can included penalties against the organization and individuals involved. All new hires will complete HIPAA training on their first day of employment. Questions? For policy questions, contact the Privacy Officer, Joe Neville at (513) 765-6341. For training questions, contact Ernest Gause at (513) 765-3374.

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EXECUTIVE SUMMARY HIPAA POLICIES AND PROCEDURES

This document contains a summary of policies and procedures adopted by Luxottica Retail in order to comply with privacy law related to health information. For a more detailed description of these policies and the procedures adopted to implement such policies, please see the HIPAA Policies and Procedures document.

1. Use and Disclosure of Health Information Luxottica Retail is committed to protecting the privacy of individually identifiable health information that is maintained or transmitted in connection with certain treatment, administrative and financial transactions. We will advise the individual about our privacy practices relating to use and disclosure of their PHI to treat the patient, obtain payment for the services we provide and other health care operations by providing the individual with a copy of our Notice of Privacy Practices ("NPP"). We will also seek written acknowledgement of receipt of the NPP. Such written acknowledgements will be kept for six years, in compliance with federal law. For any use or disclosure not addressed by our NPP, we will seek and obtain a written authorization from the individual.

2. Disclosing And Requesting Only the Minimum Amount of Protected Health Information (PHI) Necessary To support our commitment to patient confidentiality, Luxottica Retail will ensure that the appropriate steps are taken to use, disclose, or request only the minimum amount of protected health information necessary to accomplish a particular task. While patient information must be available to health care professionals in the process of ensuring proper care, we should avoid disclosing more patient information than needed to perform our respective duties. This policy generally does not apply to uses or disclosures: for treatment; to the individual who is the subject of the information; or pursuant to an authorization or those required by law.

Within Luxottica Retail, each department that handles protected health information will define classes of personnel who have or need access to protected health information on a routine basis to appropriately accomplish work-related duties, along with a description of the appropriate information to be accessed. Such listings will be maintained by each department that deals with protected health information.

PHI is defined as information created or obtained by Luxottica Retail (including demographic information) that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; and that identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

3. Using and Disclosing PHI For Marketing

Luxottica Retail will obtain individual authorization to use and disclose patient health information for the purpose of marketing, except as set forth below and permitted by law.

Luxottica Retail may, without obtaining individual authorization, use and disclose patient health information for the purpose of describing health care products and services offered by Luxottica Retail; to engage in patient/customer recall or to remind Luxottica Retail customers of the importance of regular eye examinations and schedule such if requested by the customer; and for soliciting feedback from our patients/customers.

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4. Individual Rights: Granting Access to Inspect and Obtain a Copy of PHI Luxottica Retail is committed to allowing individuals the right to access, inspect and obtain a copy of their protected health information. Policies and procedures have been adopted to carry out this right. Furthermore, it is important to ensure that individuals can receive communications regarding their protected health information in a means and location that the individual feels is safe from unauthorized use or disclosure. Procedures have been established to accomplish this purpose. Various individuals within the organization, ranging from store managers, to Managing optometrists, to the Privacy Officer, have been empowered to provide defined categories of information. Requests must, in general, be handled within 30 days of the date of request.

5. Individual Rights: Accepting Requests for Amendments to PHI Individuals have the right to request an amendment (any form of change) or correction to their protected health information. Health care entities, such as the Luxottica Retail companies, have the right to deny the request to amend or correct protected health information. Luxottica Retail has procedures for an individual to request an amendment to their protected health information for as long as the information is maintained. All requests must be in writing and, with the exception of demographic information that store associates may change, must be sent to the Privacy Officer. Generally, the law allows 30 days to process such requests.

6. Mitigating the Effect of an Unauthorized Release of PHI Luxottica Retail will take all necessary steps, to the extent practicable, to mitigate any harmful effect that is known to Luxottica Retail of a use or disclosure of protected health information in violation of Luxottica Retail policies and procedures.

7. Sanctioning of Employees, etc. Luxottica Retail will apply appropriate sanctions pursuant to its regular counseling and disciplinary rules and procedures against members of its workforce who fail to comply with the Luxottica Retail policies and procedures relating to the confidentiality of PHI.

8. Prohibiting Retaliation against Employees, etc. It is the responsibility of all Luxottica Retail employees to report perceived misconduct, including actual or potential violations of laws, regulations, policies, procedures, or the Luxottica Retail code of conduct. In accordance with usual company policy, no retaliation is permitted against such employees.

9. Obtaining Individual Authorization Luxottica Retail will comply with the law to request authorization for use or disclosure of PHI for purposes other than treatment, payment or health care operations, or other uses and disclosure permitted by law and addressed by our NPP. We will enter into Business Associate Agreements with those vendors to whom we send PHI for purposes of carrying out company operations. The Privacy Officer will manage the authorization process and retain records relating to authorizations for six years, in accordance with law. 10. Personal Representative Luxottica retail must treat a personal representative of an individual (such as a parent, guardian or person with a power of attorney) as the individual if the person has authority under law to act on behalf of the individual.

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11. Verification In the normal course of business and operations, we will receive many requests to disclose patient health information for various purposes. To support our commitment to patient confidentiality, Luxottica Retail will ensure that the appropriate steps are taken to verify the authority and identity of individuals and entities requesting protected health information. Such steps include examining photo identification or by asking open-ended questions in order to match against information in our database. We will also confirm addresses, e-mail addresses and fax numbers to ensure that any PHI transmitted is properly directed to the intended recipient. Such transmissions will always be marked "Confidential."

It is the intent of Luxottica Retail to cooperate with requests for PHI from governmental entities including, but not limited to, the police, optometry or opticianary boards and other state or federal agencies. HIPAA, however, does impose verification requirements in these instances as well, so such requests should be referred immediately to the Privacy Office.

12. Accounting Upon written request, Luxottica Retail shall provide individuals with an accounting of all instances where protected health information about them is used or disclosed. However, accountings are generally not provided in instances related to disclosures for treatment, payment or health care operations related to the individual, disclosures to the individual about their own protected health information or disclosures pursuant to a written authorization by the individual.

All requests for an accounting shall be forwarded to and will be handled by the Privacy Office.

13. Privacy/Security Breach All associates shall report known or suspected privacy breaches to the Privacy Office as soon as they are discovered. Delay to investigate a suspected privacy breach is not permitted; rather, the party discovering the breach shall immediately report it to the Privacy Office. Discovery of IT security breaches shall be reported to the Security Office, as required under separate policy of that office.

Thereafter, the company will follow the notification requirements of the law including those to affected individuals, the media and the Department of HHS, Specific and general remediation will be undertaken as appropriate.

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GENERAL STATEMENTS & DEFINITIONS

Pr ivacy Best Practices

General Statement & Definitions Doc. Version: 1.00 Page 1 of 4

Revised by: Date:

Effective Date: 4-13-03

Approval: Joe Neville

1.0 Purpose The purpose of this Policy is to describe the purpose of the policies and procedures and define certain terms.

2.0 Scope All Luxottica Retail associates and consultants with access to personal and protected health information are responsible for compliance with this Policy.

3.0 Policy

3.1 Purpose Luxottica Retail, which describes a family of companies, including LensCrafters, Pearle Vision, Sears Optical, Target Optical, EYEXAM of California, Pearle Vision Care and EyeMed, is committed to ensuring the privacy and security of patient health information. The primary federal law related to such privacy and security is the Health Insurance Portability and Accountability Act, commonly known as HIPAA. Generally, covered entities must obtain the individual's acknowledgement of receipt of the entity's privacy practices pertaining to the use and/or disclosure of protected health information ("PHI"), including uses and disclosures of PHI for purposes of treatment, payment, and health care operations, as well as other uses and/or disclosure of PHI permitted by HIPAA. PHI is defined as information created or obtained by Luxottica Retail (including demographic information) that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; and that identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

We will advise the individual about our privacy practices relating to the use and/or disclosure of their PHI by providing the individual with a copy of our Notice of Privacy Practices ("NPP") and seek written acknowledgement of receipt of such notice. For uses and/or disclosures not addressed in the Notice of Privacy Practices, we will seek and obtain a written authorization from the individual. While patient information must be available to health care professionals to ensure proper care, we should avoid disclosing more patient information than needed to perform our respective duties. To support our commitment to patient confidentiality, Luxottica Retail will ensure that the appropriate steps are taken to use or disclose only the minimum amount of protected health information necessary to accomplish a particular task, as required under 45 C.F.R. §164.502(b), 45 C.F.R. § 164.514(d), and other applicable federal, state, and/or local laws and regulations.

To enhance our services, we will solicit feedback and provide information relative to health care products and services offered by Luxottica Retail. To support our commitment to patient confidentiality, Luxottica Retail will ensure that any protected health information used or disclosed for marketing purposes will comply fully with 45 C.F.R. §§ 164.501 & 164.508(a) and other applicable federal, state, and/or local laws and regulations.

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Luxottica Retail recognizes that individual rights are a critical aspect of maintaining quality care and service, and is committed to allowing individuals to exercise their rights under 45 C.F.R. §164.524, and other applicable federal, state, and/or local laws and regulations. To support this commitment, Luxottica Retail will maintain and update, as appropriate, written policies and procedures to provide guidance on employee and organizational responsibilities regarding the rights of individuals to access, inspect and obtain a copy of their protected health information, denial of such right of access and review of such decision.

Furthermore, it is important to ensure that individuals can receive communications regarding their protected health information in a means and location that the individual feels is safe from unauthorized use or disclosure. A covered health care provider must permit individuals to request and must accommodate reasonable requests by individuals to receive communications of protected health information from the covered health care provider by alternative means or at alternative locations.

Under HIPAA, individuals have the right to request an amendment (any form of change) or correction to their protected health information. Entities have the right to deny the request to amend or correct protected health information. Unless the individual provides a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment, this provision applies to protected health information created by the covered entity.

On occasion, organizations outside Luxottica Retail may need to use or disclose protected health information that we maintain in order to provide treatment, payment, or health care operations on behalf of Luxottica Retail. In these instances, we must obtain a business associate agreement to maintain the confidentiality of the information or obtain separate authorization from the individual for the use or disclosure of the individual's protected health information by others.

Luxottica Retail has established and will apply appropriate sanctions against members of its workforce, as well as other agents and contractors, who fail to comply with its policies and procedures. Under HIPAA, penalties for misuse or misappropriation of health information include both civil monetary penalties and criminal penalties. Civil penalties range from $100 for each violation to a maximum of $25,000 per year for the same violations. Criminal penalties vary from $50,000 and/or 1 year imprisonment to $250,000 and/or 10 years imprisonment (42 U.S.C. §1320d).

Luxottica Retail, pursuant to its standard non-retaliation policy, will take all necessary steps to refrain from intimidating, threatening, coercing, discriminating against, or taking any other retaliatory action against any employee, individual, or other for the exercise of any right under, or for participation in any process established pursuant to applicable laws and/or regulations related to privacy of health care information.

Covered entities must treat a personal representative of an individual as the individual if the person has authority under law to act on behalf of the individual. This policy is designed to give guidance when Luxottica Retail is dealing with a personal representative of an individual and to ensure compliance with applicable laws and regulations. In the normal course of business and operations, we will receive many requests to disclose patient health

Privacy Best Practices

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information for various purposes. To support our commitment to patient confidentiality, Luxottica Retail will ensure that the appropriate steps are taken to verify the authority and identity of individuals and entities requesting protected health information, as required under 45 C.F.R. §164.502(g) and §164.514(h), respectively, and other applicable federal, state, and/or local laws and regulations.

HIPAA requires that individuals have a right to receive an accounting of various instances when protected health information about them is disclosed by a covered entity, subject to certain time-limited exceptions for disclosures to law enforcement and oversight agencies. Luxottica Retail has developed policies and procedures to address the accounting of instances when protected health information has been used or disclosed for purposes other than treatment, payment, or health care operations.

3.2 Definitions

For purposes of these Policies and Procedures, the following terms have the following meanings: (a) "Treatment" means the provision, coordination, or management of health care and related

services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient/customer; or the referral of a patient for health care from one health care provider to another.

(b) "Payment" means the activities undertaken by Luxottica Retail to obtain payment for the provision of health care; and relates to the individual to whom health care is provided and includes; but is not limited to;

1. Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), adjudication or subrogation of health benefit claims and processing claims for payment;

2. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related health care data processing;

3. Review of health care services with respect to medical necessity, coverage under a health plan,

appropriateness of care, or justification of charges;

4. Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; and

5. Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of reimbursement: a. Name and address; b. Date of birth; c. Social security number; d. Payment history; e. Account number; and f. Name and address of the health care provider and/or health plan

(c) "Health care operations" means any of the following activities:


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General Statement & Definitions

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1. Conducting quality assessment and improvement activities; including outcomes evaluation and development of clinical guidelines, population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives; and related functions that do not include treatment;

2. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities;

3. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs;

4. Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity; including formulary development and administration, development, or improvement of methods of payment or coverage policies; and

5. Business management and general administrative activities of Luxottica Retail, including, but not limited to: activities related to compliance with HIPAA related rules and regulations; customer service and in soliciting customer feedback; general business data analysis; provision of data analysis for policy holders, plan sponsors or other customers provided that PHI is not disclosed to such policy holder, plan sponsor or customer; resolution of grievances; auditing of financial records; the sale, transfer, merger or consolidation of all or part of Luxottica Retail with another covered entity or one that will become a covered entity;

6. Resolution of internal grievances;

7. Due diligence in connections with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity, or, following completion of the sale or transfer, will become a covered entity.

4.0 Procedure None

5.0 Forms None

6.0 Policy Questions/Changes Questions or suggested changes to this Policy must be referred to the Privacy Officer.

7.0 Revision History Version Revision Date Description Revised By 1.00 Original Document

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DISCLOSURE OF PERSONAL HEALTH INFORMATION


Use and Disclosure of PHI


1.0 Purpose The purpose of this Policy is to describe the situations under which Luxottica Retail may use or disclose the PHI of its clients customers and enrollees.

2.0 Scope All Luxottica Retail associates and consultants with access to personal and health information are responsible for compliance with this Policy.

3.0 Policy

3.1 As stated in this policy and procedure and required under 45 C.F.R. §164.520, Luxottica Retail will advise patients/ customers of our privacy practices by providing a copy of our Notice of Privacy Practices ("NPP") to each such individual or in the case of enrollees of any Luxottica Retail health plan, to each associate.

3.2 Luxottica Retail may use or disclose protected health information: (a) for its own treatment, payment, or health care operations; (b) for the treatment activities of another covered entity; (c) to another covered entity for the payment activities of the entity that receives the information; (d) to another covered entity for healthcare operations of the covered entity that receives

the information if such covered entity had or has a relationship with the individual who is the subject of the PHI, the PHI relates to that relationship and the disclosure is for purposes of items 3.2(o)1 or 2 of the definition of health care operations as found in the General Statement and Definitions or fraud or abuse detection or compliance.

3.3 PHI will not be used for any purpose other than treatment, payment or health care operations without the written authorization of the individual, except as otherwise specifically permitted by law and set forth in the Luxottica Notice of Privacy Practices.

3.4 Any different standards imposed by individual state law, which is not pre-empted by federal law or regulation, will be adhered to in such state.

4.0 Procedure None

5.0 Forms None

6.0 Policy Questions/Changes Questions or suggested changes to this Policy must be referred to the Privacy Office.

7.0 Revision History

Version Revision Date Description Revised By

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MINIMUM NECESSARY USE & DISCLOSURE


Minimum Necessary Use & Disclosure


1.0 Purpose

The purpose of this Policy is to describe the type and extent of personal or protected health information to be used in responding to legitimate requests for such information.

2.0 Scope

All Luxottica Retail associates and consultants with access to personal or protected health information are responsible for compliance with this Policy.

3.0 Policy

3.1 Luxottica Retail associates will follow proper procedures to ensure that only the minimum amount of patient health information necessary to accomplish the specific purpose of a use or disclosure is actually used or disclosed.

3.2 Luxottica Retail associates will request only the minimum amount of patient health information necessary to accomplish the specific purpose of the request.

3.3 It is the policy of Luxottica Retail that its associates should ask for necessary information to carry out treatment responsibilities rather than examining the specific patient file.

3.4 Information from optical dispensary files should only be shared with a subleasing doctor when needed for treatment, payment or health care operations.

3.5 This policy does not apply to the following uses or disclosures: (a) disclosure to or requests by a provider for treatment; (b) uses or disclosure made to the individual who is the subject of the information; (c) uses or disclosure pursuant to an authorization initiated by the individual who is the subject of

the information; (d) disclosure made to the United States Department of Health and Human Services; (e) uses or disclosures required by law; and (f) uses or disclosure required for compliance with applicable laws and regulations.

4.0 Procedure

4.1 Other than uses or disclosures exempted from this Policy by Policy Statement #3 above, all proposed uses or disclosures of patient health information will be reviewed by persons having an understanding of Luxottica Retail's privacy policies and practices, and sufficient expertise to understand and weigh the necessary factors. Policies and procedures with respect to usual and customary disclosures may be adopted to address such uses and disclosures. This may be on a departmental or functional basis.

Questions about appropriate use or disclosure should be referred to the Privacy Officer.

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Minimum Necessary Use & Disclosure


4.2 Luxottica Retail will only use, disclose, or request an entire medical record when the entire medical record is specifically justified as being reasonably necessary to accomplish the purpose of the use, disclosure, or request. Otherwise, only portions of the record will be used as required to accomplish the task at hand.

4.3 Other than requests exempted from this Policy as defined above, requests by Luxottica for protected health information from another covered entity will be reviewed by the Privacy Officer on an individual basis in accordance with this policy to ensure that only the minimum necessary protected health information is requested.

4.4 If Luxottica Retail receives a request to disclose protected health information, Luxottica Retail associates may rely, if such reliance is reasonable under the circumstances, on a requested disclosure of protected health information as the minimum necessary for the stated purpose when: (a) making disclosures to public officials if the public official represents that the information

requested is the minimum necessary for the stated purpose; (b) the information is requested by another covered entity; or (c) the information is requested by a professional who is a member of the workforce of Luxottica

Retail, or is a business associate of Luxottica Retail for the purpose of providing professional services to Luxottica Retail, if the professional or business associate represents that the information requested is the minimum necessary for the stated purpose.

All other requests received by Luxottica Retail to disclose protected health information should be forwarded to the Privacy Officer for review to insure that only the minimum necessary to accomplish the purpose for which disclosure is sought.

4.5 Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer or to the associate compliance hotline.

5.0 Forms None





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ACCESS BY PERSONNEL


Access by Personnel

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1.0 Purpose

The purpose of this Policy is to describe appropriate access by authorized personnel.

2.0 Scope All Luxottica Retail associates and consultants with access to personal and protected health information are responsible for compliance with this Policy.

3.0 Policy

3.1 On a Department basis, only those individuals with a job-related need for access to personal or protected health information will have access to such information.

3.2 Access to protected health information will be reasonably limited by utilizing access control systems, such as password protections, and physical security techniques, such as locking filing cabinets and clean desk practices.

3.3 Despite the close working relationship between Luxottica Retail associates and subleasing optometrists or ophthalmologists, no Luxottica Retail associate should handle a subleasing doctor's patient file unless it is with the specific permission of the doctor or pursuant to a Business Associate Agreement and in the course of treatment.

(A Business Associate Agreement is a contract between a provider, such as an optometrist, and another entity that provides services to the optometrist involving the use of health information and which requires the entity to maintain the confidentiality of the health information used in providing such services. Only the Regulatory Services department is authorized to approve such contracts.)

4.0 Procedure

4.1 Within Luxottica Retail, each department which handles protected health information shall define the classes of personnel who have or need access to protected health information on a routine basis to appropriately accomplish their duties and responsibilities, along with a description of the appropriate information to be accessed.

5.0 Forms

None





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MARKETING


Marketing


1.0 Purpose

The purpose of this Policy is to describe what is and is not marketing and the use of authorizations when engaging in marketing.

2.0 Scope

All Luxottica Retail associates and consultants with access to personal and protected health information are responsible for compliance with this Policy.

3.0 Policy

3.1 Luxottica Retail will obtain individual authorization to use and disclose patient health information for the purpose of marketing, as defined at 45 C.F.R. § 164.501, except as otherwise stated in this policy and procedure and allowed by law.

3.2 Luxottica Retail may, without obtaining individual authorization, use and disclose patient health information for the purpose of describing health care products and services in accordance with the procedures stated herein; to engage in patient/customer recall or to remind Luxottica Retail customers of the importance of regular eye examinations and schedule such if requested by the customer; and for soliciting feedback from our patients/customers.

4.0 Procedure

4.1 Luxottica Retail may, without obtaining individual authorization, use or disclose protected health information for the following purposes:

(a) to make a face-to-face marketing communication to an individual;

(b) for promotional gifts of nominal value provided by Luxottica Retail;

(c) to inform Luxottica Retail customers/patients about the optical and other health-related products and services of Luxottica Retail;

(d) to send reminders about the need for regular eye examinations or about a pre-scheduled appointment for eye or vision care or to help schedule such appointment if so requested by the customer;

(e) to solicit feedback relating to customer satisfaction with respect to the products and services of Luxottica Retail; or

(f) to send direct mail to EyeMed/assignment customers to remind such customers about available benefits or enhancements to benefits

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4.2 In complying with this Policy, all marketing communications will:

(a) identify at least one of the Luxottica Retail companies as the party making the communication; and

(b) prominently state that Luxottica Retail has received or will receive direct or indirect remuneration for making the communication, if such is fact.

4.3 Luxottica Retail may disclose protected health information for purposes of health care communications or marketing to a business associate that assists with such communications so long as Luxottica Retail has entered into a Business Associate agreement with such business associate.

4.4 Luxottica Retail will make reasonable efforts to ensure that individuals who ask to be omitted from receiving future communications are not sent such communications.

4.5 Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer or to the employee compliance hotline.

5.0 Forms

None

6.0 Policy Questions/Changes Questions or suggested changes to this Policy must be referred to the Privacy Office 7.0 Revision History




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CONFIDENTIAL COMMUNICATION


Confidential Communication

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1.0 Purpose

The purpose of this Policy is to describe the policy regarding customer requests for confidential communications.

2.0 Scope


3.0 Policy

3.1 It is the policy of the company to use confidential communications when specifically requested by a customer and when feasible within the scope of the systems used by the company.

3.2 Luxottica Retail will take necessary steps to accommodate reasonable requests by individuals to receive confidential communications of protected health information.

3.3 In complying with 3.2 above, Luxottica Retail will provide confidential communications by alternative means or at alternative locations, if practicable.

3.4 In the event that a confidential communication request cannot be honored, the requesting party will be so notified.

4.0 Procedure

4.1 Luxottica Retail may require individuals to make a request for a confidential communication of protected health information in writing. Luxottica Retail will not require an explanation from the individual as to the basis for the request as a condition of providing communications on a confidential basis.

5.0 Forms

None 6.0 Policy Questions/Changes

Questions or suggested changes to this Policy must be referred to the Privacy Office.




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GRANTING ACCESS TO PHI


Granting Access to PHI


1.0 Purpose

The purpose of this Policy is to describe the policies and procedures relating to a customer requesting access to records and the company's response requirements.

2.0 Scope


3.0 Policy

3.1 Luxottica Retail will take necessary steps to address individual requests to access, inspect and/or obtain a copy of their protected health information that is maintained in a designated record set ("medical" and billing records about an individual) in a timely and professional manner. (Note that information maintained in the records of the optical brands, EyeMed, EYEXAM of California and Pearle Vision Care are all considered separate record sets. A request for information from one set would not include all sets.)

3.2 Individuals may request to access, inspect and/or obtain a copy of their protected health information that is maintained in a designated record set. In instances where the protected health information is in more than one record set, or at more than one location, Luxottica Retail will only produce the protected health information once in response to a request for access.

3.3 Individuals do not have the right to access the following types of information: (a) Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or

administrative action or proceeding; (b) Psychotherapy notes; and (c) Protected health information that is:

(1) Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. §263a, to the extent the provision of access to the individual would be prohibited by law; or

(2) Exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 C.F.R. §493.3(a)(2).

3.4 The following persons are responsible for receiving and processing requests for access to protected health information by individuals: (a) Store/Dispensary Information:

(1) Store, Retail or Lab managers and designated key holders (b) Doctor Office Information:

(1) the Managing Optometrist or Patient Care Supervisor at employed offices; (2) the EYEXAM/Pearle Vision Care Managing Optometrist or Patient Care Supervisor

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(c) Health Plan Information:

(1) Luxottica Retail Compensation and Benefits Department (d) Occupational Health/Workers Compensation Information:

(1) Occupational Health Department (e) EyeMed:

(1) EyeMed Call-in Center; (2) EyeMed Client Response Team

(f) Generally: (1) the Luxottica Retail Customer Services Departments; (2) the Legal Services Department; or (3) the Privacy Officer.

In any event, all third-party requests for protected health information shall be forwarded to and processed by the Privacy Office. (Third-party requests generally are those by a non-patient/customer or by a patient/customer for another person but for whom the requesting party is not the guardian or personal representative.)

3.5 Luxottica Retail will take necessary steps to accommodate reasonable requests by individuals to receive confidential communications of protected health information.

3.6 In complying with Policy 3.5, Luxottica Retail will provide confidential communications by alternative means or at alternative locations, if practicable.

4.0 Procedure

4.1 Luxottica Retail may require individuals to direct requests for access, inspection or a copy of protected health information to the appropriate contact person, and complete a Request for Health information form, which each store maintains and can also be obtained from the Privacy Office.

4.2 In person requests for access or copies of protected health information will require positive picture identification. Store personnel may handle these immediately. Other requests must be in writing and contain sufficient information to confirm the identity of the requesting individual or additional information will be required to be submitted. In the case of a request by a personal representative, see the policy entitled "Personal Representatives.".

4.3 Luxottica Retail may require individuals to make a request for a confidential communication of protected health information in writing. Luxottica Retail will not require an explanation from the individual as to the basis for the request as a condition of providing communications on a confidential basis.




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4.4 When appropriate, Luxottica Retail may condition the provision of a reasonable accommodation on information as to how payment, if any, will be handled, and specification of an alternative address or other method of contact.

4.5 An appropriate request from an individual for access, inspection or a copy of protected health information, whether oral or using the Request for Health Information form shall be directed, within a reasonable time period, along with the form, to location-appropriate Luxottica Retail personnel as described in Policy Statement 3.4 above.

4.6 Upon receipt of a request for access, inspection or a copy of protected health information, Luxottica Retail personnel with appropriate clearance will act on the request by (1) informing the individual of the acceptance and providing the access or copies requested or (2) providing the individual with a written denial. To determine whether a request should be denied, see Procedure 4.21 herein.

4.7 Action taken pursuant to Procedure 4.6 must be taken: (a) no later than 30 days after the request is made; or, (b) if the request is for protected health information that is not maintained or accessible

on-site to Luxottica Retail, no later than 60 days after the request; unless an extension is specifically taken as described in Procedure 4.8 below.

4.8 If Luxottica Retail cannot take action on a request for access to protected health information within the relevant time periods listed in Procedure 4.7, Luxottica Retail may extend the time required by, but no more than, 30 days. If the time period for the action is extended, Luxottica Retail personnel will, within the appropriate time period, provide the individual with a written statement of the reasons for the delay and the date by which Luxottica Retail will complete the action on the request. The time period for action will not be extended more than once.

4.9 Luxottica Retail personnel with appropriate access clearance will access the individual's protected health information using proper access and authorization procedures.

4.10 The individual will be allowed access, inspection, and/or copies of the requested protected health information in a secure and confidential manner, such that the information cannot be accessed by employees or other persons who do not have appropriate access clearance to that information. Generally, access will be provided at a mutually convenient time: (a) in the optical dispensary, by viewing of the store systems screens for the individual in the

presence of a LensCrafters associate with appropriate access clearance; (b) in an employed doctor or EYEXAM/Pearle VisionCare office, by review of the individual's

file, in the presence of an appropriate associate with access clearance and in an exam, pretest or other private space within the office;

(c) in or from EyeMed through providing hard copy printout of appropriate claims systems information;

(d) for employee health or worker's comp files, in a private space at the CSC in the presence of an appropriate associate with clearance;




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Otherwise, access will be provided by mailing of such protected health information or by such other format satisfactory to both the individual and Luxottica Retail as determined in professional judgment of the Privacy Officer on a case-by-case basis and considering all relevant factors.

4.11 Luxottica Retail will provide the individual with access to the protected health information

in the form or format requested by the individual, if it is readily producible in such form or format.

4.12 If the requested format is not readily producible, then Luxottica Retail will provide the individual with access to the protected health information in a readable hard copy form or such other form as agreed to by Luxottica and the individual.

4.13 An alternative means or location for access will be designated on a case-by-case basis that is satisfactory to both Luxottica Retail and the individual, before communication of protected health information is made.

4.14 The Privacy Officer, using professional judgment and considering all relevant factors, will be responsible for deciding the alternative means or location to communicate protected health information to an individual.

4.15 A summary of the requested protected health information will be provided in lieu of access to the information only when the individual agrees in advance to a summary and to any related fees imposed.

4.16 An explanation of the requested protected health information to which access has been provided will accompany the access only when the individual agrees in advance to such explanation and to any related fees imposed.

4.17 If a summary or explanation of the requested information is to be prepared, only Luxottica Retail personnel with appropriate access clearance will complete such summary or explanation. 4.18 Any fees imposed on the individual for a copy of the protected health information or a summary or explanation of such information will:

(a) be collected by the office at the time of receipt of the request and the proper completion of the request form.

(b) be reasonable and cost-based; (c) will be only for the cost of the following;

(1) Copying, including the cost of supplies for and labor of copying, the protected health information requested by the individual;

(2) Postage, when the individual has requested the copy, or the summary or explanation, be mailed; and

(3) Preparing an explanation or summary of the protected health information.




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4.19 Luxottica Retail will document and retain documentation related to designated record sets

that are subject to access by individuals other than the individual who is the subject of such information as well as titles of individuals responsible for receiving and processing requests for access together with related policies and procedures for a period of at least 6 years from the date of its creation or the date when it last was in effect, whichever is later.

4.20 A denial of access will be issued and will not be reviewed in the following circumstances: (a) the protected health information is:

(1) Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;

(2) Psychotherapy notes; or (3) Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. §263a,

to the extent the provision of access to the individual would be prohibited by law; or exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR §493.3(a)(2).

(b) Luxottica Retail is acting under the direction of a correctional institution upon an inmate's request for a copy of the protected health information and obtaining a copy would jeopardize the health, safety, security, custody, or rehabilitation of the individual or of other inmates, or of any officer, employee, or other person at the correctional institution or responsible for the transporting of the inmate;

(c) access to protected health information that was created or obtained by Luxottica Retail in the course of research that includes treatment may be temporarily suspended for as long as the research is in progress, provided that the individual has agreed to the denial of access when consenting to participate in the research, and has been informed that the right of access will be reinstated upon completion of the research;

(d) the protected health information contained in records is subject to the Privacy Act, 5 U.S.C. §552a, and the denial of access under the Privacy Act meets the requirements of that law;

(e) the protected health information was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

All denials must be reviewed and approved by the Privacy Officer.

4.21 Luxottica Retail will review a denial for access to protected health information when requested by an individual in the following situations: (a) a licensed health care professional has determined, in the exercise of professional judgment,

that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person;

(b) the protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or

(c) the request for access is made by the individual's personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.




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4.22 All denial reviews will be conducted by a licensed health care professional (e.g., Directors of Optometric Relations, Regional Optometric Practice Managers, EyeMed Medical Director) who is designated by Luxottica Retail to act as a reviewing official and who did not participate in the original decision to deny.

4.23 The designated reviewing official will be determined on a case-by-case basis by the Privacy Officer.

4.24 Luxottica Retail personnel will promptly refer a request for review to the designated reviewing official.

4.25 The designated reviewing official will determine, within a reasonable period of time, whether or not to deny the access requested based on the applicable standards.

4.26 Luxottica Retail personnel will promptly provide written notice to the individual of the determination of the designated reviewing official and take other action as required to carry out the designated reviewing official's determination.

4.27 In denying access in whole or in part, to the extent possible, appropriate Luxottica Retail personnel will give the individual access to any other protected health information requested,

After excluding the protected health information that was denied.

4.28 When denying an individual access to protected health information, the denial will: (a) be written in plain language; (b) contain the basis for the denial; (c) unless the individual does not have the right to have the denial review in accordance with

Section 20 above, contain the following statement: THE INDIVIDUAL HAS THE RIGHT TO HAVE THE DENIAL REVIEWED BY A LICENSED HEALTH CARE PROFESSIONAL, DESIGNATED BY LUXOTTICA RETAIL, TO ACT AS A REVIEWING OFFICIAL AND WHO DID NOT PARTICIPATE IN THE ORIGINAL DENIAL DECISION;

(d) inform that individuals may exercise their review rights by writing to the Privacy Officer, detailing the individual's request and the basis for such request;

(e) contain a description of how the individual may complain to Luxottica Retail pursuant to its complaint procedures or to the DH HS Secretary.

4.29 The description of how the individual may complain will include the name, or title, and telephone number of the contact person or office designated to receive such complaints.

4.30 Complaints will be directed in writing to: Privacy Office, Luxottica Retail 4000 Luxottica Place Mason, OH 45040 or via email to privacyofficenluxotticaretail.com. All complaints should contain the name of the complaining individual, the location where last serviced, the event(s) upon which the complaint is based and a detailed description of the actual complaint together with any specific relief requested. No anonymous complaints will be handled.




http://privacyofficenluxotticaretail.com/

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4.31 For all complaints not related to a denial of access, acknowledgement of such complaint will be made within 30 days of receipt of the complaint and a final response provided within 60 days of such complaint, unless Luxottica Retail takes an extension. Such extension shall not exceed 30 days and only one such extension will be taken.

4.32 In the event that Luxottica Retail does not maintain the health information that is the subject of the individual's request for access but knows where it is maintained, Luxottica Retail personnel

will inform the individual where to direct the request for access.

4.33 In the event that the identity and legal authority of an individual or entity requesting protected health information cannot be verified, personnel will refrain from disclosing the equested information and report the case to the Privacy Officer in a timely manner.

4.34 Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer or to the associate compliance hotline.

5.0 Forms See Attached

6.0 Policy Questions/Changes





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INDIVIDUAL REQUEST FOR ACCESS TO PERSONAL HEALTH INFORMATION

As provided by the Health Insurance Portability and Accountability Act, you have a right of access to inspect and obtain a copy of your health information contained in a designated record set. This right does not apply to:

1) Psychotherapy notes;

2) Information compiled in reasonable anticipation of, or for use in a civil, criminal, or administrative action or proceeding; and

3) Protected health information that is: a) Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. 263a, to the

extent the provision of access to you would be prohibited by law; or b) Exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR

493.3(a)(2). Please indicate specifically the information to which you are requesting access: _______________

Luxottica Retail will act on this request within 30 days of the date listed above or, within 60 days if the requested information is not maintained or accessible to Luxottica Retail on-site. If Luxottica Retail is unable to respond to such request within the stated time period, it may extend the response time by up to 30 days by providing you with notice of the extension and reason for the delay. Such action will either inform you of the acceptance of the request and provide you with the requested access; or provide a written denial explaining the reasons for the denial and whether you are entitled to have the denial reviewed.

If the requested information is contained in more than one designated record set or at more than one location, and access is granted, Luxottica Retail needs only to provide you with access to information contained on one of the designated record sets.

Please indicate the form or format you would like to receive your requested information:

Please indicate the means by which you wish to inspect or obtain a copy of the requested information (fax, mail, on-site, etc., and provide the necessary numbers or address): If Luxottica Retail cannot readily produce the Information in the form or format you have requested such information will be made available to you in a readable hard copy form or other form or format agreed to by us.

Do you agree to receive a summary of the requested information in lieu of access? ___ Yes _____No

Luxottica Retail may Impose a fee of $2.00/page to cover the cost of labor, copying, postage, and preparing a summary of the requested information (unless such fee is otherwise dictated by state law). Do you agree to such fees imposed by Luxottica Retail for providing a copy or summary of the requested information? ___ Yes _____ No _____________________________________________ ______________________________ Name Today’s Date




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Name Address

Social Security #EMAIL address (if any)

Signature FOR OFFICE USE: Date this request was received by Luxottica Retail : __________________




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COMPLAINTS


Complaints


1.0 Purpose

The purpose of this Policy is to describe the process for the receipt and handling of complaints related to personal and health information.

2.0 Scope


3.0 Policy

3.1 It is the policy of the Company to receive all complaints related to the privacy protection of personal and protected health information and process them in a timely manner.

4.0 Procedure

4.1 Complaints will be directed in writing to: Privacy Office Luxottica Retail

4000 Luxottica Place Mason, OH 45040

or via email to [email protected]. All complaints should contain the name of the complaining individual, the location where last serviced, the event(s) upon which the complaint is based and a detailed description of the actual complaint together with any specific relief requested. No anonymous complaints will be handled.

4.2 For all complaints not related to a denial of access, acknowledgement of such complaint will be made within 30 days of receipt of the complaint and a final response provided within 60 days of such complaint, unless Luxottica Retail takes an extension. Such extension shall not exceed 30 days and only one such extension will be taken.

5.0 Forms - None

6.0 Policy Questions/Changes Questions or suggested changes to this Policy must be referred to the Privacy Office. 7.0 Revision History




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AMENDMENTS TO PHI


Amendments to PHI


1.0 Purpose

The purpose of this Policy is to describe when and how an individual may make a request for amendment to protected health information or a record in a designated record set.

2.0 Scope All Luxottica Retail associates and consultants with access to protected health information are

responsible for compliance with this Policy.

3.0 Policy 3.1 Luxottica Retail will allow an individual to request an amendment to their protected health information

or a record in a designated record set for as long as the information is maintained in a designated record set (generally, "medical" and billing records about an individual).

3.2 Luxottica Retail will allow an individual to request amendment to their protected health information that was not created by Luxottica Retail if provided a reasonable basis to believe that the originator of the information is no longer available to act on the request.

4.0 Procedure 4.1 Requests directed to the optical dispensaries or doctor's offices for changes to demographic

information or record changes due to remakes will be handled directly by personnel in the dispensary or doctor office. For all other dispensary/office requests, dispensary and doctor office personnel will be responsible for receiving requests for amendments to protected health information, which are then to be forwarded to the office of the Privacy Officer. For requests related to employed or EYEXAM doctor offices, the Privacy Officer will work with the Director of Optometric Practices Group for employed optometrist offices and the Executive Optometric Director for EYEXAM of California/Pearle VisionCare to resolve such requests. Requests related to EyeMed will be handled in cooperation with the Director of Call Center Operations for EyeMed. Group health plan related requests shall be forwarded directly to the Director of Compensation and Benefits for Luxottica Retail.

4.2 All individual requests for amendments to protected or other health information must be in writing.

4.3 Individuals must document the reason(s) to support the requested amendment.

4.4 The request will be referred to a designated health care professional for review, who will be selected by the individuals identified in Procedure 4.1 above on a case-by-case basis.

4.5 The Privacy Officer shall inform the individual no later than 30 or 60 days, as applicable, after receipt of such a request if the amendment is accepted.

4.6 The time period for the action by Luxottica Retail may be extended by no more than 30 days.

4.7 If the time period for the action needs to be extended, the Privacy Officer shall, within 60 days after receipt of the request, provide the individual with a written statement of the reasons for the delay and the date by which Luxottica Retail will complete the action on the request.

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4.8 The time period for action shall not be extended more than once. 4.9 If the requested amendment is accepted, the Privacy officer will: (a) make the appropriate amendment; or

(b) arrange to have the necessary health care professional make the amendment.

4.10 Upon accepting and completing a requested amendment, the Privacy Officer will perform the following tasks: (a) inform the individual, in a timely manner, and obtain the individual's identification of and

agreement to have Luxottica Retail notify the relevant persons with which the amendment needs to be shared;

(b) make reasonable efforts to inform and provide the amendment within a reasonable time to persons identified by the individual as needing the amendment;

(c) make reasonable efforts to inform and provide the amendment within a reasonable time to persons, including business associates that are known to have the affected protected health information and that may have relied, or could foreseeably rely, on such information to the detriment of the individual.

4.11 In completing the amendment the Privacy Officer will, at a minimum, identify the affected information in the designated record set and append or otherwise provide a link to the location

of the amendment.

4.12 In the event that another covered entity notifies Luxottica Retail of an amendment to an individual's protected health information, the Privacy Officer will amend the respective information by, at minimum, identifying the affected information in the designated record set and appending or otherwise providing a link to the location of the amendment.

4.13 An individual's request for amendment may be denied if the requested amendment pertains to protected health information that:

(a) was not created by Luxottica Retail; (b) is not part of the designated record set; (c) would not be available for inspection under the requirements for individual rights to

access protected health information (see policy entitled "Granting Access to PHI"); or (d) is accurate and complete.

4.14 If the requested amendment is denied, the denial shall be written in plain language and shall contain the following: (a) the basis for the denial; (b) the individual's right to submit a written statement disagreeing with the denial; (c) a description of how the individual may file such a statement; (d) a description of how the individual may file a complaint to Luxottica Retail pursuant to

its compliant procedures including the name, or title, and telephone number of the contact person or office designated to receive such complaints;

(e) a description of how the individual may file a complaint with the Department of Health and Human Services;

(f) the following statement - IF INDIVIDUAL DOES NOT SUBMIT A STATEMENT OF DISAGREEMENT, THEN INDIVIDUAL MAY REQUEST LUXOTTICA RETAIL TO PROVIDE THE INDIVIDUAL'S REQUEST FOR AMENDMENT AND THE DENIAL WITH ANY FUTURE DISCLOSURES OF THE PROTECTED HEALTH INFORMATION THAT IS THE SUBJECT OF THE AMENDMENT.


Amendments to PHI


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4.15 If the individual provides a statement of disagreement, Luxottica Retail may prepare a written rebuttal to the individual's statement of disagreement.

4.16 Luxottica Retail will provide the individual with a copy of the above rebuttal.

4.17 Luxottica Retail will append or otherwise link the following to the designated record set or protected health information that is the subject of the disputed amendment: (a) the individual's request for an amendment; (b) the denial of the request; (c) the individual's statement of disagreement, if any; and (d) Luxottica Retail's rebuttal, if any.

4.18 Any subsequent disclosures of the protected health information to which an individual's written disagreement relates will include the following: (a) the material appended as described above; or (b) an accurate summary of any such information.

4.19 Subsequent disclosures may be transmitted separately from a standard transaction if the standard transaction does not allow the information in Procedure 4.18 to be transmitted.

4.20 If the individual has not submitted a written statement of disagreement, Luxottica Retail will include the individual's request for amendment and Luxottica Retail's denial, or an accurate summary of such information, with any subsequent disclosure of the protected health information only if the individual has requested such action.

5.0 Forms

None

6.0 Policy Questions/Changes Questions or suggested changes to this Policy must be referred to the Privacy Office





Amendments to PHI


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MITGATING EFFECTS OF UNAUTHORIZED USE


Mitigating Effect of Unauthorized Release


1.0 Purpose

The purpose of this Policy is to describe the policy and process for investigating allegations of improper use and/or disclosure of personal and protected health information and mitigating the effect of any such improper use or disclosure.

2.0 Scope


3.0 Policy

3.1 Pursuant to 45 C.F.R. §164.530(f), Luxottica Retail will take all necessary steps, to the extent practicable, to mitigate any harmful effect that is known to Luxottica Retail of a use or disclosure of protected health information in violation of Luxottica Retail policies and procedures.

4.0 Procedure

4.1 Luxottica Retail will utilize the following process to mitigate the effect of an unauthorized release of protected health information by an employee: (a) Any unauthorized use or release of protected health information will be immediately

reported to the Privacy Officer upon discovery of the release. (b) The Privacy Officer, in conjunction with appropriate company officials, will determine the

nature and scope of the unauthorized use or release. (c) Luxottica Retail will use appropriate efforts to seek the return and/or destruction of the

information. (d) Luxottica Retail will take such other steps as deemed appropriate to mitigate the effect of

such unauthorized use or release.

4.2 Luxottica Retail will utilize the following process to mitigate the effect of an unauthorized release of information by a business associate: (a) Any unauthorized release of protected health information will be immediately reported to

Privacy Officer upon discovery of the release. (b) Luxottica Retail will use appropriate efforts to seek the return and/or destruction of the

information.

5.0 Forms

None



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GR:HIPAA P&P/HIPAA P&P11 Mitigation 11-08


Mitigating Effect of Unauthorized Release


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SANCTIONS


Sanctions


1.0 Purpose

The purpose of this Policy is to describe the policy and process for determining and applying sanctions for violation of policies regarding the proper use and disclosure of personal and protected health information.

2.0 Scope


3.0 Policy

3.1 Luxottica Retail will apply appropriate sanctions pursuant to its regular counseling and disciplinary rules and procedures against members of its workforce who fail to comply with the Luxottica Retail policies and procedures relating to the confidentiality of personal or protected health information.

3.2 The type of sanction applied shall vary depending on the severity of the violation, whether the violation was intentional or unintentional, whether the violation indicates a pattern or practice of improper access, use or disclosure of personal or health information, and similar factors.

3.3 Employees, agents, and other contractors should be aware that violations of a severe nature may result in notification to law enforcement officials as well as regulatory, accreditation, and/or iicensure organizations.

3.4 The policy and procedures contained herein do not apply specifically when members of Luxottica Retail's workforce exercise their right to:

(a) file a complaint with the U.S. Department of Health and Human Services ("DHHS"); (b) testify, assist, or participate in an investigation, compliance review, proceeding, or hearing

under Part C of Title XI; (c) oppose any act made unlawful by the HIPAA privacy rule; provided the individual or person

has a good faith belief that the act opposed is unlawful, and the manner of the opposition is reasonable and does not involve a disclosure of protected health information in violation of the H1PAA privacy rule; or

(d) disclose protected health information as a whistleblower and the disclosure is to a health oversight agency; public health authority; or an attorney retained by the individual for purposes of determining the individuals legal options with regard to the whistleblower activity.

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Sanctions


4.0 Procedure

4.1 The company will follow its usual performance counseling process as set forth in the Luxottica Retail Associate Guide book (or such other similar document).

4.2 The Human Resources Department in conjunction with the Privacy Officer is responsible for determining the severity of sanctions necessary.

4.3 All sanctioning of employees will be documented and retained for a period of at least 6 years from the date of its creation or the date when it was last in effect, whichever is later.

5.0 Forms

None






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PROHIBITING RETALIATION


Prohibiting Retaliation


1.0 Purpose

The purpose of this Policy is to describe the anti-retaliation policy of the Company.

2.0 Scope


3.0 Policy

3.1 It is the responsibility of all Luxottica Retail employees to report perceived misconduct, including actual or potential violations of laws, regulations, policies, procedures, or the Luxottica Retail code of conduct.

3.2 Luxottica Retail maintains an "open-door policy" at all levels of management to encourage employees to report problems and concerns.

3.3 Luxottica Retail will follow all usual procedures to protect against any retaliation toward any employee, individual, or other for exercising their rights or participating in any process pursuant to internal policies, applicable law, and/or regulation related to these policies.

3.4 Any employee who commits or condones any form of retaliation will be subject to discipline up to, and including, termination.

4.0 Procedure None

5.0 Forms None 6.0 Policy Questions/Changes





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OBTAINING INDIVIDUAL AUTHORIZATION


Obtaining Individual Authorization


1.0 Purpose

The purpose of this Policy is to describe when individual authorization is required and the process for obtaining such authorization.

2.0 Scope


3.0 Policy

3.1 Luxottica Retail will comply with the requirements set forth in 45 C.F.R. §164.508, to request authorization for use or disclosure of PHI for purposes other than Treatment, Payment or Health Care Operations, or other uses and/or disclosures of PHI specifically permitted by HIPAA and set forth in the Luxottica Notice of Privacy Practices.

3.2 Luxottica Retail may not condition treatment, payment, enrollment, or eligibility on the provision of an authorization, except for provision of research-related treatment, which is health care provided solely for the purpose of creating PHI for disclosure to a third party or as part of health plan operations related to enrollment or eligibility, all as specifically provided in §163.508(b)(4).

4.0 Procedure

4.1 The authorization will be written in plain language.

4.2 Any authorization initiated by Luxottica Retail for the disclosure of protected health information for use by another entity will contain the following: (a) a description of the information to be used or disclosed that identifies the information in a

specific and meaningful fashion; (b) a description of each purpose of the requested disclosure; (c) the name or other specific identification of the person(s), or class of persons, authorized to

make the requested use or disclosure; (d) the name or other specific identification of the person(s), or class of persons, to whom

Luxottica Retail may make the requested use or disclosure; (e) an expiration date or an expiration event that relates to the individual or the purpose of

the use or disclosure; (f) a statement of the individual's right to revoke the authorization in writing and the

exceptions to the right to revoke; (g) a description of how the individual may revoke the authorization; (h) a statement that information used or disclosed pursuant to the authorization may be

subject to redisclosure by the recipient and no longer protected by 45 C.F.R. Part 164; (i) the signature of the individual; or signature of personal representative with a description

of the representative's authority to act for the individual; and date;

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(j) a statement that the individual may refuse to sign the authorization; (k) a statement that the covered entity will not condition treatment, payment,

enrollment in the health plan, or eligibility for benefits on the individual's providing authorization for the requested use or disclosure, except as permitted by law.

4.3 In addition, as part of the authorization process, Luxottica Retail will provide individuals with any facts they need to make an informed decision as to whether to allow disclosure of the information.

4.4 Luxottica Retail will document and retain the signed authorization for a period of at least 6 years from the date of its creation or the date when it last was in effect, whichever is later.

4.5 Luxottica Retail will provide the individual with a copy of the signed authorization.

5.0 Forms

See Attached.

6.0 Policy Questions l Changes





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AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.

1. Persons/organizations authorized to use or disclose the information [Circle One]:

LensCrafters / EYEXAM of California / EyeMed Managed Vision Care

2. Persons/organizations authorized to receive the information:

3. Specific description of information that may be used/disclosed:

Items 4-6 only apply if Luxottica Retail is requesting the information for its own uses and disclosures. 4. The information will be used/disclosed for the following purposes [Check One]:

( ) At the Request of the Individual ( ) Other-Please Describe:

5. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law.

6. The organization authorized to use/disclose the information will receive compensation for doing so.

Yes No

7. I understand that I may inspect or copy the information used or disclosed.

8. I understand that I may revoke this authorization at any time by notifying the person/organization providing the information in writing, except to the extent that:

a) action has been taken in reliance on this authorization; or b) if this authorization is obtained as a condition for obtaining insurance coverage, other law

provides the insurer with the right to contest a claim under the policy.

9. This authorization expires on [upon] [INSERT APPLICABLE DATE OR EVENT]: __________

Signature of patient or patient's representative Date

Printed name of patient or patient's representative Relationship to patient or representative's

authority to act for the patient

(A copy of this signed form will be provided to the patient)




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PERSONAL REPRESENTATIVES


Personal Representatives


1.0 Purpose

The purpose of this Policy is to describe policies and procedures relating to the determination of and interactions with personal representatives.

2.0 Scope


3.0 Policy

3.1 If under applicable law a person has authority to act on behalf of an individual who is an adult or an emancipated minor in making decisions related to health care, Luxottica Retail will treat such person as a personal representative with respect to protected health information relevant to such personal representation.

3.2 With respect to unemancipated minors, deceased individuals, and others, Luxottica Retail will follow these procedures in determining whether to treat a person as a personal representative of an individual.

4.0 Procedure

4.1 Luxottica Retail will treat a person as a personal representative of an individual with respect to disclosure of protected health information ("PHI") if under applicable law: (a) the person has authority (e.g., guardianship, power of attorney) to act on behalf of an

individual who is an adult or an emancipated minor in making decisions related to health care;

(b) a parent, guardian, or other person acting in loco parentis (in the place of a parent) has authority to act on behalf of an individual who is an unemancipated minor in making decisions related to health care; or

(c) an executor, administrator, or other person has authority to act on behalf of a deceased individual or of the individual's estate.

4.2 Luxottica Retail will treat a person as a personal representative of a deceased individual with respect to the PHI relevant to such representation, if under applicable law the person is an executor, administrator, or other person with authority to act on behalf of the deceased individual or of the individual's estate.

4.3 In the following circumstances Luxottica Retail will not treat a person as a personal representative of an unemancipated minor, when the minor has authority to act with respect to their PHI pertaining to a health care service: (a) if the minor consents to such health care service; (b) if the minor may lawfully obtain such health care service without the consent of a parent,

guardian, or other person acting in loco parentis, and the minor, a court, or another person authorized by lw consents to such health care service; or

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(c) A parent, guardian, or other person acting in loco parent's assents to an agreement of confidentiality between a covered health care provider and the minor with respect to such health care service.

4.4 Luxottica Retail will not treat a person as the personal representative of an individual if: (a) Luxottica Retail has a reasonable belief that the individual has been or may be

subjected to domestic violence, abuse, or neglect by such person; or treating such person as the personal representative could endanger the individual; or

(b) Luxottica Retail, in the exercise of professional judgment, decides that it is not in the best interest of the individual to treat the person as the individual's personal representative.

4.5 In many cases it may be necessary to consult State law for rules regarding disclosure and access in that State law might control. To the extent that the law is not clear in this area, the access or disclosure decision will be made by a licensed health care professional, exercising professional judgment, and as chosen by the Privacy Officer.

5.0 Forms

None


Questions or suggested changes to this Policy must be referred to the Privacy Office. 7.0 Revision History



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COMMUNICATING WITH FAMILY & OTHERS INVOLVED IN CARE


Communicating with Family, Others Involved in Care


1.0 Purpose

The purpose of this Policy is to describe general rules concerning the release of PHI to family, friends or others involved in the care of an individual.

2.0 Scope


3.0 Policy

3.1 Luxottica Retail may disclose limited information to family, friends, HR benefit administrators or others involved in an individual's care if the individual does not object or the Luxottica Retail associate can reasonably infer from the circumstances that the individual does not object to the disclosure.

3.2 When the individual that is the subject of the information is not present or is incapacitated the Luxottica Retail associate can make the disclosure if, in the exercise of professional judgment, it believes the disclosure is in the best interest of the individual.

3.3 Any information disclosed may only be the minimum necessary and only that directly related to the inquiring person's involvement with the individual's care.

3.4 The company will accept written authorization to share information with others as designated by the individual signing such authorization. 3.5 Standard verification procedures will be used with all such disclosures. 3.6 Any questions related to sharing under this policy must be referred to the Privacy Office.

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4.0 Procedure

4.1 In every instance of a request by a family member, etc., determine the relationship to the individual that is the subject of the information.

4.2 If available, obtain the permission of the individual who is the subject of the request to share information with the designated requesting party. Use standard verification procedures related to the individual.

4.3 If the individual is not present, use professional judgment to determine if sharing is in the best interest of the individual. Again, use standard verification procedures relating to the individual that is the subject of the request.

4.4 Share only the minimum information necessary to fulfill the request. In general, diagnosis or procedure codes should not be disclosed, however, use professional judgment in deciding whether to disclose this information if it is requested.

4.5 Record the requesting party's name, phone number and a description of the information supplied.

5.0 Forms The attached form may be used in the event that an individual wishes to designate an individual to receive information.






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AUTHORIZATION TO [LUXOTTICA RETAIL/EYENIED1 TO RELEASE PHI TO DESIGNATED PARTY Date: Patient / Customer Name: (Please print)

This Authorization grants permission to the Designated Party(ies) named below, with respect to my eye/vision care, to: be made aware of my diagnosis, prognosis and treatment plans, receive copies of my vision/eye care records, have access to and receive copies of my financial, health and/or vision insurance information, make or confirm appointments and pick up vision care products.

(Print Name of Designated Party) (Relationship to Individual)

(Print Name of Designated Party) (Relationship to Individual) This information may be used or disclosed at the request of the Designated Party unless otherwise limited as follows (please print any limitations):

This authorization is made voluntarily by me. I understand that my treatment cannot be conditioned on whether I sign this authorization.

This authorization is good for my lifetime, however, I understand that I may revoke this designation at any time by signing the revocation section below and returning it to the Privacy Office, Luxottica Retail, 4000 Luxottica Place, Mason, OH 45040, and that any cancellation can only apply to future disclosures or actions regarding my protected health information and cannot cancel actions taken or disclosures made while the authorization was in effect.

I understand that once this information is disclosed to the Designated Party(ies), the released information may no longer be protected by federal privacy regulations.

Signature: _________________________

Date of birth: ________________ Phone:

Address:

REVOCATION SECTION:

This authorization is hereby revoked. Signature:_________________________________________ Date: ______________________

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VERIFICATION


Verification


1.0 Purpose

The purpose of this Policy is to describe required process for verifying identity for purposes of disclosing personal or protected health information.

2.0 Scope


3.0 Policy

3.1 Luxottica Retail will take necessary steps to verify the identity and legal authority of persons requesting disclosure of protected health information.

4.0 Procedure

4.1 In verifying the identity and legal authority of a public official or a person acting on behalf of the public official requesting disclosure of protected health information, Luxottica Retail personnel may rely on the following, if such reliance is reasonable under the circumstances, when disclosing protected health information: (a) documentation, statements, or representations that, on their face, meet the applicable

requirements for a disclosure of protected health information; (b) presentation of an agency identification badge, other official credentials, or other proof of

government status if the request is made in person; (c) a written statement on appropriate government letterhead that the person is acting under

the government's authority; (d) other evidence or documentation from an agency, such as a contract for services,

memorandum of understanding, or purchase order, that establishes that the person is acting on behalf of the public official;

(e) a written statement of the legal authority under which the information is requested; (f) if a written statement would be impracticable, an oral statement of such legal authority; or (g) a request that is made pursuant to a warrant, subpoena, order, or other legal process issued

by a grand jury or a judicial or administrative tribunal that is presumed to constitute legal authority.

Any doubts concerning the identity or authority of a public official should be resolved by contacting the Privacy Officer.

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4.2 Any in-person or telephonic request by a public official, including but not limited to a representative

or investigator for a state optometry or optician board, department of health or professions or other governmental agency, shall be immediately referred to the Regulatory Services Department, as is required under general company policy. It is the intent of Luxottica Retail to cooperate with appropriate governmental requests or investigations; however, the Regulatory Services department must be contacted before providing any materials, including patient information. Written requests and subpoenas must be forwarded immediately to Regulatory Services or Legal Services, pursuant to regular company policy.

4.3 Luxottica Retail personnel may rely on the exercise of professional judgment in making the following uses or disclosures of protected health information: (a) a use or disclosure for facility directories; (b) a use or disclosure to others involved in the individual's care, or acting on a good faith belief in

making a disclosure to avert a serious threat to health and safety.

4.4 Personnel receiving a request from an individual or entity for use or disclosure of protected health information will use patient files, Tab, (and related brand specific Point of Sale systems), EyeMed Claims System or other available systems to determine whether Luxottica Retail has a known relationship with the requesting individual.

4.5 For in-person verifications, Luxottica Retail personnel shall request a photo identification to verify the identification of the requesting individual. In the event that the individual does not have a photo ID or the transaction is not in-person, personnel shall ask for other forms of identification and compare to or ask open ended questions related to personal information in Luxottica Retail's files pertaining to the individual (e.g., "what is your...address, birth date, doctor/provider name, name of vision care plan and/or identifications numbers related to such plan").

4.6 In the case of information requested about a minor child, Luxottica Retail personnel shall ask for a photo ID or other form of identification of the requesting adult and ask questions to determine that the adult acting for the child has the requisite relationship to the child.

4.7 In the event that the requesting party presents as the personal representative of the individual for whom records are requested, Luxottica Retail personnel shall request written documentation of such status in the form of a Power of Attorney, guardianship, written authorization or other signed appointment as a personal representative. A photo ID or other form of identification shall also be required to verify the identity of the requesting party.

4.8 Telephonic requests for PHI or telephone conversations which involve a discussion of PHI will require the Luxottica Retail personnel to ask questions of the caller to verify identity based upon data already in the Luxottica Retail file. (See examples in Procedure 4.5 above.)


Verification


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4.9 "Email" requests involving questions (based on information in the file) about or a discussion of PHI shall require an acknowledgement back to the sender which asks questions in order to verify the

identity of the sender. Such questions must be answered before a response addressing PHI can be given. A confidentiality statement will be attached to all emails admonishing that confidential information is included and is designed to be read only by the addressee and that any emails inadvertently received must be returned or destroyed.

4.10 Paper requests for PHI or information related to PHI should contain an authorization to disclose or sufficient information about the individual to confirm that it is the owner of that information. Otherwise, Luxottica Retail personnel must obtain verification of identity in the forms set forth in this policy and procedure.

4.11 Personnel will report any discrepancies in the verification of the identity and/or legal

authority of an individual or entity requesting PHI to the Privacy Officer in a timely manner.

4.12 Once it is determined that use or disclosure is appropriate, Luxottica Retail personnel with appropriate access clearance will access the individual’s protected health information using proper access and authorization procedures.

4.13 The requested protected health information will be delivered to the individual in a secure and confidential manner, such that the information cannot be accessed by employees or other persons who do not have appropriate access clearance to that information.

4.14 Luxottica Retail personnel will appropriately document the request and delivery of the protected health information through notes to the file.

4.15 In the event that the identity and legal authority of an individual or entity requesting protected health information cannot be verified, personnel will refrain from disclosing the requested information and report the case to the Privacy Officer in a timely manner.

4.16 Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer.

5.0 Forms None






Verification


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RIGHTS TO AN ACCOUNTING


Rights to an Accounting


1.0 Purpose

The purpose of this Policy is to describe policies and procedures relating to requests for an accounting of use or disclosure of protected health information.

2.0 Scope

All Luxottica Retail associates and consultants with access to protected health information are responsible for compliance with this Policy.

3.0 Policy

3.1 Upon written request, Luxottica Retail shall provide individuals with an accounting of all instances where protected health information about them is used or disclosed.

3.2 Luxottica Retail shall provide such accounting except for the following purposes:

(a) to carry out treatment, payment and health care operations; (b) to the individuals about their own protected health information; (c) pursuant to a written authorization by the individual; (d) for the facility's directory; (e) to persons involved in the individual's care or other notification purposes; (f) for national security or intelligence purposes; (g) to correctional institutions or law enforcement custodial situations.

3.3 Luxottica Retail will not provide an accounting of instances where protected health information about them was used or disclosed prior to April 13, 2003.

4.0 Procedure

4.1 All requests for an accounting shall be directed to and will be processed by the privacy officer. All such requests must be in writing.

4.2 Luxottica Retail will provide an accounting of disclosures of protected health information made by Luxottica Retail in the six years prior to the date on which the accounting is requested but only for disclosures made after April 13, 2003.

4.3 The accounting will be in writing.

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4.4 Each accounting of a disclosure will include the following: (a) the date of disclosure; (b) the name of the entity or person who received the protected health

information and, if known, the address of such entity or person; (c) a brief description of the protected health information disclosed;

(d) a brief statement of the purpose of the disclosure that reasonably

informs the individual of the basis for the disclosure; or in lieu of such statement:

(e) a copy of the individual's written authorization to use or disclose the protected health information, or

(f) a copy of a written request for a disclosure required by the DHHS Secretary to investigate or determine the covered entity's compliance with applicable laws and regulations.

4.5 Luxottica Retail will act on the individual's request for an accounting not later than 60 days after receipt of the request by: (a) providing the individual with the accounting requested, or (b) extending the time to provide the accounting by no more than 30 days.

4.6 in the event that Luxottica Retail extends the time to provide the accounting, within 60 days after receipt of the request, it will provide the individual with a written statement of the reasons for the delay and the date by which the covered entity will provide the accounting.

4.7 Luxottica Retail will not extend the time to provide the accounting more than once.

4.8 The first accounting to an individual in any 12-month period will be without charge.

4.9 Any fee imposed by Luxottica Retail for each subsequent request for an accounting by the same individual within the 12-month period will be cost-based.

4.10 Upon imposing a fee Luxottica Retail will inform the individual in advance of the fee and provide the individual with an opportunity to withdraw or modify the request for a subsequent accounting in order to avoid or reduce the fee.




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4.11 Luxottica Retail will document and retain the following for a period of at least 6 years, or from the date of its creation or the date when it last was in effect, whichever is later: (a) the information required to be included in an accounting; (b) the written accounting that is provided to the individual; (c) the title of the persons or officer responsible for receiving and processing requests for an

accounting by individual.

4.12 The Privacy Officer is responsible for responding to a request from an individual for an audit trail of instances when their protected health information has been disclosed for purposes other than treatment, payment, or health care operations.

5.0 Forms

None









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PRIVACY BREACH


Privacy Breach


1.0 Purpose

The purpose of this Policy is to describe process for response to a privacy breach, as defined in regulation, in the Luxottica Retail system.

2.0 Scope

All Luxottica Retail associates and consultants with access to protected Health information are responsible for compliance with this Policy. Reporting privacy breaches to the Privacy Office is the responsibility of anyone who becomes aware of such.

3.0 Policy

3.1 It is the policy of Luxottica Retail that all associates shall report known or suspected privacy breaches to the Privacy Office as soon as they are discovered. Delay to investigate a suspected privacy breach is not permitted; rather, the party discovering the breach shall immediately report it to the Privacy Office. Discovery of IT security breaches shall be reported to the Security Office, as required under separate policy of that office.

3.2 Luxottica Retail will thereafter follow the requirements set forth below.

4.0 Procedure

4.1 Notification to individuals affected by breach

(a) Without unreasonable delay, but in no event more than 60 days after discovery of a breach, Luxottica Retail will provide notice, as provided for in regulation, to the affected individuals.

(b) Such notice will contain:

(1) A brief notice of what happened including the date of the breach and the date of the discovery of the breach, if known;

(2) A description of the types of unsecured PHI that were involved in the breach;

(3) Any steps individuals should take to protect themselves from potential harm resulting from the breach;

(4) A brief description of what Luxottica retail is doing to investigate the breach, to mitigate harm and to protect against further breaches;

(5) Contact procedures for individuals to ask questions or learn additional information, which shall include a toll-free number, an email address, Web site or postal address,

(c) Notices will either be via first class mail or email, if the individual has given permission for electronic notice, or via substitute notice, all as set forth in regulation.

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Privacy Breach


4.2 Other Notice

(a) To the media

(1) For a breach involving more than 500 residents of a State or jurisdiction, Luxottica Retail will notify prominent media outlets serving such State or jurisdiction of such breach.

(2) Such notice will be without unreasonable delay but no later than 60 days after discovery of the breach. It will contain the same information as set forth above relating to notice to individuals.

(c) To the Secretary of HHS

(1) In the event that the breach involves more than 500 individuals, notice shall be given contemporaneously with that given to affected individuals, and containing the same information as that required for individual notice and as set forth in regulation.

(2) For breaches involving less than 500 people, Luxottica Retail will maintain a log of such breaches and, not later than 60 days after the end of each calendar year, provide the same notice as set forth in paragraph a. above, as required on the HHS Web site.

4.3 Following recovery from privacy breach incidents:

(a) reviews should be performed to determine the cause and effect of the privacy breach and corresponding recovery actions

(b) existing privacy controls should be examined to determine their adequacy and

(c) corrective actions should be undertaken to minimize the risk of similar incidents occurring.

5.0 Forms 5.1 None


Questions or suggested changes to this Policy must be referred to the Privacy Office. 7.0 Revision History



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HIPAA – FREQUENTLY ASKED QUESTIONS Q: We often receive letters or pictures from customers thanking us or showing us how they look in their new glasses. We have always posted these in a place where other customers can see them. Does HIPAA prevent us from doing this now? A: Yes, unfortunately, it does. A specific authorization from the customer would be necessary to post such materials, which is not very practical. You could post these materials in a private break room or office, but not out in the open for other customers to see. If the letter is such that you could completely black out all references to the customer’s name, you could then post the de-identified letter. Q: A celebrity came into our store the other day. It was not only a fantastic and fun experience, but we heard back that she thought we did a great job and will only use our store in the future. I would like to share the celebrity’s name and the experience with the Region, is that still okay? A: Unfortunately no, this is no longer legal under HIPAA. While these can be great stories to tell, it is not possible to reveal the name of customers in this manner. It is okay to tell the basic customer service story, but the customer’s name cannot be used and the customer cannot be described in such a way that others will be able to identify the customer. This is not just true with celebrities. The same rules apply to all customers. A specific, written authorization is necessary to disclose this kind of information. Q: Marketing and Gift of Sight fund raising opt out- Customers tell me they do not want to be contacted to contribute or to receive LensCrafters marketing – what do I do about these situations? A: There are two answers here, As for Gift of Sight fund raising – we do not solicit customers (or the public at-large) to contribute to the GOS. For that reason, there is no opt-out list. The GOS reference is in the NPP because the government requires it and if we ever did want to solicit customers, we would need the reference in the NPP. Rather than go through the hassle of changing the NPP in the future, the reference was put in now to preserve our rights. You can tell those who ask that we do not solicit customers but if we ever did start, we would create an opt-out list at that point. Concerning LensCrafters marketing – you already have a procedure to put customers on an opt-out list and should continue to follow that procedure in these cases. Call Michelle Balastra at CSC (513) 765-6247, if you have questions about this procedure. Q: A friend of family member brings in an Rx asking to have it filled for the customer/patient named on the script. Can we fill this Rx? A: Yes, you can. You can assume that the friend or family member has been asked by the customer to bring in the Rx. In accepting the Rx you are not sharing any PHI with friend/family member so you do not have a use or disclosure issue. Put the customer’s name on the Acknowledgment Log and have the friend/family member sign, indication the relationship of the signer to the customer. The same question has come up in the context of a customer who is unable to come into the store because she is disabled in some capacity, for example, in a nursing home or injured and cannot travel. The same answer is true in these cases. An added element in a few examples is that the person coming into the store has a power of attorney for the disabled individual. In that case, you are in even better shape because such power gives them the right to act for the other person. While it is not necessary for ordering eye wear, it is extra verification that should give you comfort in proceeding. [Note: over the phone contact lens refill orders can fall into this category as well.] There are probably fitting issues you need to remember in this scenario, so don’t forget about those, but they do not pose HIPAA issues.

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Q: How about the situation where the friend/family member wants to pick up the finished glasses or contact lenses? Can I deliver the finished product to the friend/family member? A: Yes, you can do that as well. The government’s comments to the HIPAA rule make it clear that if this is a usual circumstance, you can continue to engage in this practice. The government assumes that if a friend/family member has stopped by to pick up something specific, that the actual customer gave them the authority to do so. You can make the same assumption unless you detect that there is something unusual or “not quite right” about the request. (Don’t forget the possible fitting issues here as well.)

Q: What about the situation where the family member/friend is asking to pick up a copy of the customer’s records, Rx or other PHI? Can I release that as well? A: In general, no. To begin with let’s be sure to understand that a family member/friend cannot request such records on behalf of the customer. Unless there is a specific authorization from the customer, only the customer can request such records. Again, absent an authorization, we can only disclose the PHI to the customer. Perhaps an easy answer is to fax the information to the customer. (Be sure to verify the fax number and use the “Confidential Fax Sheet.”) In a spouse situation if, for example, the husband gives an oral authorization for the wife to pick up the information, releasing the information to the wife is appropriate. In that case, seal the PHI in an envelope, put the customer’s name on it and mark the envelope confidential.

Q: How do safety programs fit into all of this? I have managers that are used to getting copies of receipts for safety eyewear produced for their employees and still want those receipts. Can we continue to give those to the manager? A: Yes, you can but the minimum necessary rule will come into play. We can share because the manager for the company is involved in the payment for the safety eyewear. In many cases the employees charge the eyewear to the company account or see a company credit card to pay for the safety eyewear. The manager needs to see the receipts or a summary to verify the actual product purchases. In many cases there is nothing more than the employees’ names and an account/credit card number on the receipt. The minimum necessary rule is clearly met in this case (using or disclosing only the least amount of information/PHI to accomplish the task).

If the manager needs to see prescription information, which is appropriate as well because the manager may need to verify that prescription safety eyewear paid for was produced. However, no other information such as diagnosis should be included.

Q: A women comes in with a broken pair of glasses that she explains belong to her spouse and wants a replacement under the BPP program. What can we do? A: You can do whatever the BPP program allows. Just like in the family member/Friend examples, you can help. You do not need to share PHI in order to accomplish this task, so you are free to proceed. Don’t forgot, to verify the women’s identity on the front end of this transaction and follow NPP procedure if this is a first visit since April 14, 2003. Q: Then how about the situation where an individual wants to buy a pair of Rx sunglasses for his girlfriend as a surprise – the girlfriend was in last week and purchased regular glasses, the boyfriend has the sunglass frame style number and wants to make the purchase? A: Similar answer but with a twist. You can make the sunglasses (don’t forget fitting issues) and sell them to the boyfriend. At this point you have not disclosed any PHI. The twist comes with respect to the paperwork you can give to the boyfriend. The paperwork should not have the script on it because that is PHI and cannot be shared in this circumstance. (This is not the same as the family member/friend picking something up at the request of the customer.) If you would typically give that information to the

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customer, you might consider mailing it to the actual wearer, the girlfriend in this example, or simply letting the boyfriend know that his girlfriend can pick that up at her convenience.

Q: A customer says that his friend just purchased a really cool pair of prescription glasses at the store and that he would like the same frame. He asks you to look up the records of the friend so he can get the same frames. Can we do that? A: No, you cannot. This is a bit of a fine line example but in following through you are indirectly acknowledging that the friend was in for a health care service. The frame has become a part of PHI because it is part of the prescription eyewear and HIPAA does not permit release of that information. While it is true that the friend is wearing the evidence right on his face, this goes beyond what we are permitted to do. I recommend that the customer try to get the friend on the phone to get the name of the frame. If this was a call-in example it is even easier because you could tell the customer exactly what you need to know and the friend could look at his receipt and write it down.

Q: A customer calls in and asks us to mail him receipts for the glasses that both he and his spouse purchased so that he can send them to his Flexible Spending Account. Can we do that? A: Unfortunately, we have to split some hairs here, but we can still get to the same result. In general, HIPAA does not allow us to share PHI with a spouse. Assuming that there is PHI on the receipt, we cannot send the wife’s receipt to the husband without an authorization from the wife. In order to meet the customer’s needs, however, and after verifying identity and address (the address for both needs to be the same) mail the receipts separately to each individual.

If the address for the two of them is not the same, you might be dealing with a divorce situation or some unusual circumstance. In that case, you could mail the husband his receipt but would need the wife to call in to request her copy.

Q: A women calls checking on the status of her spouse’s glasses which are a special order. Can we tel her if they are in or give her an estimate on when to expect them? A: After verifying identity, yes you can.

Q: A customer wants to use their insurance benefit but did not bring the card in with them. The customer’s spouse was in recently using the benefit, so the identification number is on file. Can we look into the spouse’s record for the number if the insured identifies the customer? A: Yes. Be careful not to disclose any PHI about the spouse in doing this look-up. Otherwise, follow normal insurance procedures.

Q: Same scenario as above except the spouse is the insured. Can we still do the look-up? A: Yes, you can still do the look-up.

Q: Can we discuss payment issues about a customer with an insurance company? A: Yes. Recall that we can use or disclose PHI for purposes of Treatment, Payment or Health Care Operations. If the question relates to the customer’s insurance, that falls into the Payment category and is permitted. Be sure to verify that you actually have an insurance company representative on the line.

Q: What do I do if another optical or an outside optical or an outside doctor office calls and wants a copy of a customer’s script information? A: There are two parts to this answer. First, understand that doctors, optical companies and mail order contact lens companies (a school nurse could fit in here, too) are part of the treatment chain and health information can be shared with them. If another office calls and says the customer/patient wants the information sent to that office we can rely on that request and send the information.

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Second, however, is the need to verify that the person requesting the information is who they represent themselves to be. So, take their request and how to get to them; double check their callback information in the phone book or by calling back later and checking how they answer the phone to be sure it is a doctor’s office or optical. Assuming all is fine – which it most likely will be – send the requested information. Mark the envelope “Confidential” or use a “Confidential” fax sheet and let the recipient know it is coming by fax.

Q: But do I need to use a Request for Access form or some consent form in that circumstance? A: No. That form is just for use when the customer asks for access or a copy of her record (other than one that the store/office can print out on the spot). There is no need for a separate consent as that is not required when sending to another provider.

Q: But what about getting information from another doctor or optical – is there a special release or authorization form that I need to use? Some offices won’t release patient/customer information without one. A: Since we are a provider (also a Covered Entity) and the information is requested for Treatment purposes, an authorization or release is not necessary for the doctor or optical to disclose PHI to us. Unfortunately, many providers do not understand this and are incorrectly asking for an authorization or release. While you can try to explain our right to receive this information, I have attached an authorization form for this purpose that you can copy and use.

Q: Is it okay to leave a voice mail message for a customer/patient? A: Yes, answering machine or voice mail messages are permitted; however, be careful how much information is left on the message. Simply informing the customer that glasses or contacts are ready is fine. Reminding the patient about a scheduled appointment is also appropriate but my suggestion is to limit the message to the doctor’s name and time of appointment. Leaving test results or a diagnosis on a message is not appropriate. Leaving the least amount of information on the message is a good rule-of-thumb.

Q: How can we be sure that a customer has signed the Acknowledgment Log if they come in sometime in the future? Is there an indication or a screen that can be added to CHOWto help us with this? A: We are willing to make some assumptions here. Because we have impressed on all associates the importance of our HIPAA procedures and we have trained everyone in these procedures, we are relying on each associate to carefully follow the new procedures to offer the NPP and secure a signature. Consequently, in the future if you check CHOWor the customer’s last visit and see one since April 14, 2003 you can assume that your co-worker followed procedure and presented the NPP and had the customer sign the Log. If you ask the customer if they are familiar with our privacy practices and have signed the Log and they say yes, you can also rely on that. If you have any doubts, simply present the NPP and go through the full process.

At some time in the future, we will have an indication on CHOW to show whether the customer has signed the Log. The IT department has this idea on their list of CHOW changes.

Q: Does the customer need to sign the Acknowledgement Log each time they visit the store? A: No. They only need to sign the Log when they are presented the NPP on their first visit after April 14, 2003.

Q: Do we have to give an NPP to a customer every time they visit the store or with each new transaction? A: No. We only need to present the NPP on the customer’s first visit after April 14, 2003.

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Q: What about the Acknowledgment Log - all those names on the Log for everyone to see must be a violation of HIPAA? A: This is not a violation of HIPAA. It also falls into the category of an “incidental disclosure.” Plus, there is no health information on the Log itself. If you are worried, turn the Log over at the dispensing counter, but a customer seeing another customer’s name when signing is not a violation of the law.

Q: A customer comes in and wants to know if their insurance can be used again. Do we need to give them the NPP at that point? A: I would (assuming this is the first visit since April 14, 2003). You are using their PHI at that point so I would use this as an opportunity to educate them about our privacy practices. While this is not technically a service delivery to the customer, it is a good time to offer the NPP as well.

Q: What if a customer has been to different LensCrafters Stores? Does each store need to present an NPP and obtain a signature on the Acknowledgment Log? A: No. We only need to present the NPP and secure a signature on the Log once – the first visit after April 14, 2003. There is no harm in presenting and signing more than once, but it is not necessary.

Q: What if I run out of NPPs or Logs? What do I do then? A: There are reorder numbers on each of these; however, do not ever run out of these materials. The law requires that we distribute these as we have already discussed, so running out is not an excuse. Planning ahead is critical.

Q: In an employed doctor office setting, is it necessary for the patient to sign for NPP in both the doctor’s office and the dispensary? A: No. One NPP and one signature is all that is required. Because of the legal relationship between LensCrafters and EYEXAM of California, Inc., the same is true there. If the patient starts in the doctor office, the privacy discussion starts there. That means that the doctor office as well as the dispensary will have copies of the NPP and Acknowledgment Log. Otherwise, the discussion could occur at the front desk/cash wrap or at the dispensing station.

Q: Just what exactly am I supposed to shred? A: Simple answer – everything that contains PHI. Therefore, if the document has prescription or health information on it or was generated as the result of our using PHI, it is protected and must be shredded. Receipts for prescription eyewear, DCRs or health records need to be shredded. An example of something that is not protected and does not need to be shredded is a receipt or order for plano sunglasses or a receipt for some other non-prescription accessory. When in doubt, however, shred. The trick will be planning how to do this throughout the day so that one is not left with a big pile of paper to shred. Space the work out to save your sanity and prolong the life of the shredder. Do not forget, however, that we still have record retention guidelines and they still need to be followed; however, if HIPAA requires longer retention, the longer timeline will be observed.

Q: In the employed doctor setting, who among the dispensary associates are permitted access to the patient files on the doctor side of the business? A: Assuming that all of the associates are cross-trained, all of the location’s associates may have access to the legitimate Treatment, Payment or Health Care Operations purposes. (Remember that even with access, one should only use a file when needed for actual care or service to the patient/customer and only to the minimum amount necessary.) If an associate only has a limited role in the location that does not include functions related to the doctor side, such associates should not be given access to the patient files. In that case, the associate should ask an associate with proper access to look up information that might be needed to serve the customer.

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Q: What about the subleasing setting – are we allowed access to the doctor’s patient files? What if the doctor wants us to have access such as during times when the doctor’s office is closed? A: No, LensCrafters associates are not permitted to have access to the subleasing doctor’s and should never pull a file without the doctor’s permission. If a LensCrafters associate thinks they need information from the doctor’s file, ask an employee of the doctor for the information. Modified sublease locations where LensCrafters associates serve in a technician role for the doctor are exceptions to this rule as those folks are operating under the instruction and supervision of the doctor.

If the doctor needs for us to have access to his files after hours, there is a separate agreement we can enter into and the doctor should contact the RDO, DOR or Sublease Coordinator for details on that agreement.

Q: In the situation where the doctor’s office is closing for the day and they ask us to keep the appointment book (or the next day’s page) in order to take calls and book appointments for them, can we still provide that service? A: That practice is still appropriate. The doctor is asking us to perform a function for him. We have a Business Associate agreement with each subleasing doctor which allows us to perform such functions but where we agree to keep the information confidential and not use it for our own purposes.

Q: We routinely look at the subleasing doctor’s appointment book, with their permission, to determine if any of our past customers will be in the location. We do that in order to better prepare for the customer stopping into our dispensary after the appointment with the doctor. Can we still do that? A: The HIPAA rules only allow the doctor to disclose patient information to us for Treatment, Payment or Health Care Operations. Looking at the appointment book for the reasons described above does not fall into any of those categories. We would be using the doctor’s information for our own purposes and that is prohibited by HIPAA. Consequently, we should no longer review the doctor’s appointment book for this purpose. There is an alternative. If the doctor is willing to ask the patient for permission to share their name with us and the patient says yes, the doctor could “flag” those patients’ names and provide them to us (for example, in a written, daily list).

Here is a possible script: o Doctor’s staff: Thank you for the appointment Mr. Smith. Since we are located next to

LensCrafters, do you anticipate stopping in there to look at eyeglasses after your exam? o Mr. Smith: Yes, I think I will stop in to see about new eyeglasses. o Doctor’s staff: In that case would you like us to inform them that you are coming so they

can better prepare for your visit? o Mr. Smith: Yes that would be great. Thanks.

In that case the doctor can share the name and is protected in doing so. While the distinction between this situation and the one in the previous question may seem small, HIPAA does make this distinction and we are bound by it.

Q: There is a connection between our dispensary and the subleasing doctor’s office at the back of the store. The doctor has files back there in an open Jeter. Customers use the rest rooms back there. Is there something LensCrafters needs to do about those files? A: No. The files are the doctor’s responsibility. You might, however, want to remind the doctor that the files are there and that with customers using that area the doctor might want to consider another way to protect the files.

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Q: Is there something special I need to do with the dispensing tray that comes out of the lab while awaiting customer pick-up? Can I still put the customer’s name on the tray? A: The preferred procedure is to keep the tray “behind the glass” in the lab or in a cabinet at the counter in order to avoid access to the information in the tray (name/Rx) by other customers. That is not possible in all stores so we recommend that the tray be turned side-ways as an alternative, if feasible. Those are best practices but not always possible in every store. Understand that others seeing customers names is not a violation of HIPAA. That is what is called an “incidental disclosure.” As long as we follow our privacy procedures, an incidental disclosure is not a violation of the law.

As crazy as it sounds, we are also trying to avoid someone from grabbing either the product or the script information found in the tray. The bottom line is that we need to take reasonable steps to protect the information and you may need to come up with practical solutions in your store to accomplish that.

Q: What other information protection should I be worried about? A: Some stores take the stores copy of receipts and lay them on the counter, in the open. That needs to change as well. The receipts should be placed in a locked drawer, in a closed cabinet or behind the glass – somewhat where they are not obvious and cannot be stolen. The HIPAA rules are important, but so is the danger of identity theft, so paper with health or other identifying information must be properly stored and disposed of in every case.

Q: At what age can someone purchase glasses if they are a minor? (15, 16, 17 years old?) Do they need a parent signature to sign the acknowledgement log? A: The age a minor can engage in a transaction is dictated by each state’s law. HIPAA does not directly address this issue. If the minor is permitted to make such a purchase, they can also sign the acknowledgement log. The process that has been followed with respect to minors before HIPAA, can be followed after the implementation of HIPAA procedures.

Q: What if a customer wants us to print a copy of their prescription (from CHOW) to take to another optical retailer. Can we do that? A: If a customer requests a copy of their own record as maintained in CHOW or any other point of sale system, a copy should be printed and given to the customer (assuming you have first requested and verified identity). Such record is not considered to be a prescription (script) that can be filled but can be used as confirmation of information already in the possession of the other optical retailer.

Q: We keep our Medicare Insurance Information under our cash wrap area in pull out drawers that are not locked. Is this OK? A: It is okay provided you are satisfied that the information is secure. If the public is known to get into the area or to open the drawers, another storage place will need to be used.

Q: We have to keep seven years’ worth of Medicare forms at the store. Currently, we have then in taped shut boxes in the bathroom and the break room. Do these boxes need to be locked up? A: If there is no public access to the areas in which the boxes are kept, they do not need to be locked up. If the public is permitted to use the bathroom or the break room with supervision, the Medicare information and any other protected health information (other files/DCRs) will need to be relocated.

Q: Can special orders that need to be called in or have been called in remain by the phone, or do they need to be moved behind the glass? A: The basic principle to keep in mind is that we must protect or maintain the privacy of all PHI. Consequently, any document with PHI should be protected. In the first case, that means not leaving the

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information in the open where it could be seen or picked up by non-associates. That could mean putting it behind glass, in a drawer or in some other secure location.

Q: What is a medical record in the context of store operations? What can I change? A: The better phrase is “health records” and any information we collect, as part of filling a script is health information – and protected under HIPAA. For the most part, there will be few requests to change any of the dispensary information except for demographic information (name, address, phone number, DOD, etc,) and store associates are permitted to change that information. (Such changes should not be forwarded to the Privacy Office.) A remake is not a change in the health information, so process those as usual. For any other requests to change information, contact the Privacy Office to help work through the issue.

Q: All of the store associates have been trained and our HIPAA procedures are in place. What about new store associates, do they have to be trained? A: Yes. From April 14, 2003 forward all new LensCrafters/EYEXAM associates must be trained in our HIPAA policies and procedures. It also must be one of the first training programs the new associate takes. Completion is strongly recommended during their first day in the store.

Q: I have an employee on Medical leave, who, won’t be returning until after April 14, 2003. What do I do? I have the same question for casual part-time employees, those who only work for us in the summer. What do we do about their training? A: On the first day these employees report back to work, have them complete the HIPAA training. Q: I have received a call from an outside company saying that everyone in the store must go through HIPAA training and trying to sign us all up. What should I do? A: Unfortunately there will be scams related to HIPAA. Everyone must be trained but all Luxottica Retail associates are receiving training from the company (CD-Rom or Intranet). That is all the training that is required. No outside training is required and we have not delegated any of our training to any outside company. Simply say “no thanks” and hang up. If calls of this nature become harassing, let the Privacy Officer know and we will follow up from there.

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NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES

EYEXAM of California

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

OUR LEGAL DUTIES

EYEXAM of California (“EYEXAM”) is committed to protecting your privacy. This Notice tells about the uses and disclosures we make of your personal health information, including certain rights that you have, and obligations we (EYEXAM) are bound to, with respect to such information. We are required by applicable federal and state law to do the following:

Maintain the privacy and safeguard the security of your health information;

Give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information;

Notify you, along with all other affected individuals, of a breach of unsecured health information; and

Follow the privacy practices that are described in this Notice while it is in effect.

This Notice takes effect August 15, 2013, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you at your next visit or it can be viewed in the store or on our Web site. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. We will request that you sign an acknowledgement of receiving of this Notice, but your decision not to sign the acknowledgement will not affect your ability to obtain treatment. ______________________________________________________________________________

A. USES AND DISCLOSURES OF HEALTH INFORMATION

We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care and service that you receive. Your health information is contained in a medical record that is the physical property of EYEXAM.

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Your health information consists of any information, whether in oral or recorded form, that is created or received by us and individually identifies you, and that relates to your past, present or future physical or mental health or condition; the provision of health care to you; or the past, present or future payment for the provision of health care to you. How We May Use or Disclose Your Health Information

For Treatment. We may use or disclose your health information to an optometrist, ophthalmologist, optician or other health care providers providing treatment to you for:

the provision, coordination, or management of health care and related services by health care providers;

consultation between health care providers relating to a patient/customer;

the referral of a patient for health care from one health care provider to another; or

appointment and refill reminders, and recall information. For Payment. We may use and disclose your health information to others for purposes of processing and receiving payment for treatment and services provided to you. This may include:

billing and collection activities and related data processing;

actions by a health plan or insurer to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims;

medical necessity and appropriateness of care reviews, utilization review activities; and

disclosure to consumer reporting agencies of information relating to collection of payments.

For Health Care Operations. We may use and disclose health information about you for health care operational purposes. For example, your health information may be disclosed to:

evaluate the performance of our associates;

assess the quality of service, product and care in your case and similar cases;

learn how to improve our facilities and services;

conduct training programs or credentialing activities;

facilitate compliance functions, auditing and legal services;

determine how to continually improve the quality and effectiveness of the products, service and care we provide, including customer satisfaction surveys and data analyses;

properly manage our business, including acquisitions, mergers and consolidations; and

communicate with you concerning (a) a health-related product or service that is provided by us, (b) your treatment, or (c) case management, care coordination or to recommend alternative treatments, therapies, providers or settings for care to the extent such activities are not within your current treatment. However, if we receive compensation for making a communication concerning another entity’s products or services (other than payment for treatment), the communication is “marketing” and will require that we obtain your prior written authorization as described in the Marketing section, below.

Appointments, Treatment and Quality Assurance. We may use your information to provide appointment and refill reminders or recall notices (such as voicemail messages, postcards or letters) or information about treatment alternatives or other health-related benefits, products and services that may be of interest to you. We may also contact you to conduct our own surveys about the quality of the products and services we provide.

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Fund Raising. We may use certain information (name, address, telephone number, age, date of birth, gender, dates of service, treating provider, outcome information and insurance status) to contact you in the future to raise money for our institutionally related charity, OneSight. The money raised will be used to expand and improve the health care services and programs we provide the community. You have the right to opt out of such fundraising communications by contacting the privacy office identified at the end of this Notice, or as instructed in the fundraising communication.

To You, Your Family and Friends. We must disclose your health information to you, as described in the Your Health Information Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

Persons Involved in Care. We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location or your general condition. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, photos, or other similar forms of health information.

Required by Law. We may use and disclose information about you as permitted or required by applicable law. For example, we may disclose information for the following purposes:

for judicial and administrative proceedings pursuant to court order or specific legal authority;

pursuant to a shared/joint custody and child care or support arrangement authorized by law or court order;

to report information related to victims of abuse, neglect or domestic violence;

to assist law enforcement officials in their law enforcement duties; or

to assist public health, safety or law enforcement officials avert a serious threat to the health or safety of you or any other person.

Personal Representatives; Decedents. We may disclose your health information to your personal representatives authorized under applicable law, such as a guardian, power of attorney for health care, or court-appointed administrator. Your health Information may also be disclosed to executors, legally authorized family members, funeral directors or coroners to enable them to carry out their lawful duties upon your death.

Organ/Tissue Donation. Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes, provided we follow applicable laws.

Research. We may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

Government Functions. Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.

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Management and Administration. We may disclose your health information when necessary for the proper management and administration of our business and for fulfilling our legal responsibilities, including disclosures to certain advisors and consultants when necessary, subject to applicable confidentiality and business associate agreement requirements. Worker Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Worker Compensation.

Marketing Products or Services. “Marketing” means to make a communication to you that encourages you to purchase or use a product or service. We will not use or disclose your health information for marketing communications without your prior written authorization. However, we may conduct face to face communications between you and us, and we may offer a promotional gift of nominal value, without such authorization. We may also provide you with information regarding products or services that we offer related to your health care needs, provided that we are not paid or otherwise receive compensation for such communications. We are also permitted to communicate with you regarding health-related products or services (including information about entities participating in our provider network or health plan), treatment, case management or care coordination (including recommending alternative treatments, providers or settings for care). However, if we will receive compensation (directly or indirectly) in return for making any such communications, we must first obtain your written authorization, unless the communication describes only a drug or biologic that is currently prescribed for you and any compensation we receive relates solely to the cost of making the communication. This requirement does not apply to any payment or compensation for providing treatment to you.

Sale of Your Health Information. We will never sell your health information without your prior authorization. However, we, or our business associate, may receive compensation (directly or indirectly) related to an exchange of your health information for the following purposes: (a) public health activities; (b) research purposes (if the price charged reflects the cost of preparation and transmittal of the information); (c) payment or compensation for your treatment; (d) health care operations related to the sale, merger or consolidation of all or part of our business; (c) performance of services by a business associate on our behalf; (f) providing you with a copy of your health information; or (g) other reasons determined necessary or appropriate by applicable laws or regulations.

Electronic Disclosures. We use and disclose your health information electronically for various purposes such as treatment, payment (including, where applicable, performing insurance and health maintenance organization/managed care functions), health care operations and other purposes permitted or required by law, including electronic disclosures to our business associates. If we need to disclose your health information electronically for other purposes, we will obtain your authorization, either in writing or electronically, as described in this Notice.

Your Authorization. In addition to our use or disclosure of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any other purpose. We will not condition your current or future treatment on the basis of providing an authorization. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

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B. YOUR HEALTH INFORMATION RIGHTS

Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You may be asked to make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We may charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice setting forth the specific information to which you desire access. If you request an alternative format, provided that it is practicable for us to produce the information in such format, we may charge a cost-based fee for preparing and transmitting your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a cost-based fee. If we use or maintain an electronic health record (“EHR”) with respect to your care, you have the right to request a copy of your information in electronic format, and to direct us to transmit a copy of your information to a third party designated by you; and our fee may not exceed our labor costs in responding to such request. Please contact us using the information listed at the end of this Notice for a full explanation of our fee structure. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, health care operations, where you have provided an authorization and certain other activities, for the last 6 years (or a shorter period if our relationship with you has existed for less than 6 years). If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. With respect to disclosures made by our business associates, we may choose to provide you with a list of business associates acting on our behalf, along with their contact information, who must provide you with the accounting upon a request made directly by you to such entities. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. Except as noted below, we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Upon your request, and except as otherwise required by law, we will not disclose your health information to a health plan for purposes of payment or health care operations when the information relates solely to a service/product for which you paid out-of-pocket in full. Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. You may obtain a form to request an amendment to your health information by using the contact information listed at the end of this Notice.

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Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form, as well. Breach of Unsecured Health Information: If we discover that your health information has been breached (for example, disclosed to or acquired by an unauthorized person, stolen, lost, or otherwise used or disclosed in violation of applicable privacy law) and the privacy or security of the information has been compromised, we must notify you of the breach without unreasonable delay and in no event later than 60 days following our discovery of the breach.

PRIVACY QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have privacy questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may separately choose to file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights (OCR), by completing a Health Information Privacy Complaint Form (available at http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf) and sending to the applicable OCR Regional Office listed on the form, or by calling 1-800-368-1019 for instructions and contact information. An electronic complaint may be filed at http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. You must file a complaint with OCR within 180 days (6 months) after the occurrence of the act or omission giving rise to your complaint. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the Office of Civil Rights.

Contact Information

If you have any questions or complaints relating to privacy, please contact: Privacy Office EYEXAM of California 4000 Luxottica Place Mason, Ohio 45040 Phone: 513-765-4321 Email: [email protected] Thank you for entrusting EYEXAM of California with your eye care needs.

http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf

http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html


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FORMS & MEMOS: SEE SECTION 10 OR USE HYPERLINK BELOW

Introduction for Filing Suspected Child Abuse Report Form SS8572 Suspected Child Abuse Report Form SS8572

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Section 10: EYEXAM OF CALIFORNIA, INC. CORPORATE OFFICE

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Rev. 9/11/2019

EYEXAM of California, Inc. Organization Chart

QAC Voting Members

Paul Michelson M.D. Cindy Chiang O.D.

Meredith Barber O.D Laheqa Sulikui O.D. Rozanne Fratto O.D.

Aaron Lam O.D. Jodi Shepard, O.D.

Alice Tien, O.D

Non-Voting

Members

President

SECD SMM

Controller Doctor Scheduling

Grievance Coordinator

Board of Directors Carl Spear O.D.

Dana Nakagawa O.D. Scott Perusek

Cindy Chiang O.D. Clinical Director

Chairperson of QAC

Kathy Cook Grievance Specialist

Dana Nakagawa O.D. Senior Director of Eye Care Operations

Sandra Bartaniyan Doctor Specialist

Lisa Isenhart Controller

Stephen Hoopes Sr. Pricing Analyst

Janet Kim O.D Senior Director of Eye Care Operations

EYEXAM Offices Vision Care Providers

EYEXAM Offices Vision Care Providers

Rev. 9

/11

/20

19

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Section 11: REFERENCE FORMS

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SUGGESTION/COMPLAINT FORM (ENGLISH)

SUGGESTION/COMPLAINT FORM

INSTRUCTIONS:

Please use this form for filing complaints or grievances, or for making suggestions relating to

your EYEXAM Plan, it’s services, personnel, offices, or any other aspect of the Plan that affects

you as a member.

1. Please type or print the information requested below.

2. Return this form by mail to: EYEXAM of California, Inc.

P.O. Box 2756

Mission Viejo, CA 92690

www.eyexamofca.com

3. You will receive a written acknowledgement or receipt within five (5) days,

And usually, a complete response will be made within thirty (30) days.

4. If you need assistance or have questions regarding the grievance process,

please call EYEXAM at 1-888-439-3392. The Plan also has a TDD line

1-949-364-1289 for the hearing impaired.

MEMBER NAME: _____________________________________________________________

Last First Initial

MEMBER ADDRESS: __________________________________________________________

__________________________________________________________

MEMBER TELEPHONE: ________________________________________________________

________________________________________________________

GROUP I.D. NUMBER: _________________________________________________________

_________________________________________________________

TYPE OF MEMBERSHIP: Individual ( ) Group ( )

If Group, name of Group: ________________________________________________________

http://www.eyexamofca.com/

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If you are completing this form on behalf of the EYEXAM member, please give your name,

Relationship to the Member, address and telephone number below:

Name/Relationship: _____________________________________________________________

Address: ______________________________________________________________________

Telephone: ____________________________________________________________________

SUGGESTION OR COMPLAINT: (Please include the details leading to your suggestion or complaint, such as

the date, location and names or others involved.)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

____________________________________________________

Signature of Member or Representative Date

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a

grievance against your health plan you should first telephone your health plan at (888) 439-3392 and use your health

plan’s grievance process before contacting the Department. The Plan also has a TDD line (949) 364-1289 for the hearing

impaired. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available

to you. If you need help with a grievance involving an emergency, a grievance that has remained unresolved for more

than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review

(IMR). If your are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a

health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatment that are

experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department

has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech

impaired. The Department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms,

and instructions online.

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SUGGESTION/COMPLAINT FORM (CHINESE)

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SUGGESTION/COMPLAINT FORM (SPANISH)

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SUGGESTION/COMPLAINT FORM (VIETNAMESE)

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REVIEW OF GRIEVANCE NOTIFICATION TEMPLATE

To: Cindy Chiang, O.D., Clinical Director

[Name], O.D., Senior Eye Care Director, Region ___

From: Kathy Cook, Grievance Coordinator

Date: [Date]

Re: Review of Grievance for Potential Quality Issue Attached is a grievance received on [date].

Primary (P1)/Secondary (S1, S2, S3…) Grievance Categorie(s) Presented:

___G1 Doctor/Professionalism * ___G9 CL Release ___G17a Access/Office

___G2 Eye Exam * ___G10 Membership ___G17b Access/Appointment

___G3 Prescription* ___G11 Distribution ___G17c Access/Urgent

___G4 Service/Associate ___G12 Product ___G17d Access/Emergent

___G5 Refund ___G13 CL Prescription* ___G18 Appeals

___G6 Coupon/3rd

Party ___G14 Pricing ___G19 Denials

___G7 Insurance Billing ___G15 Clinical Issues* ___G20 Expedited

___G8 CL Replacement ___G16 Miscellaneous ___G21 LAP

*Additional Sub Codes:

*G1- Doctor/Professionalism: complaints related to the doctor’s behavior, service, clinical conduct, performance

and practice

Sub codes:

G1-a Doctor acted unethically or unprofessionally.



G1-d Doctor refused to see last appointment of the day due to leaving

G1-e Doctor unfamiliar with how the ancillary equipment and/or testing





G1-j Doctor communicated possible diagnosis in a way that caused undue fear

G1-k Doctor unfamiliar with exam equipment

G1-l Doctor did not appropriately answer patient’s questions/concerns

*G2-Eye Exam: Complaints related to any component of the pretest, exam, CL evaluation or ancillary services.

Sub codes:

G2-a Associate failed to inform patient of any additional pricing for ancillary services.

G2-b Associate seemed to be unfamiliar with the pretest equipment.


G2-d Patient was not given appropriate instruction or time when learning to insert/remove new contact lens.


G2-f Patient felt that the equipment or exam/pretest room was dirty.



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*G3- Prescription: Complaints related to any aspect of the spectacle prescription

G3-a Prescription incorrect



G3-d Optician did not take the adequate time to check patient’s glasses to ensure they were able to see and fit correctly


G3-f Issues the patient may have had with their eyewear


*G13- CL Prescription: Complaints related to any aspect of the contact lens prescription

Sub codes:




G13-d Can’t get a convenient appointment to see the doctor for a CL F/U appointment.


G13-f Patient upset that they have to come back in for a f/u appointment.

G13-g Patient has not been taught how to insert and remove CLs.

G15- Clinical Issues: Complaints concerning possible medical quality of care issues, patient incidents involving product,

therapeutic/diagnostic agents, solutions, exam equipment, etc.

Sub Categories:

G15-a Patient contracted infection






Brief Summary of Grievance:

Issue involving location [office #] patient [Name].

Please see attached grievance transmittal received by

o Phone: [grievance line voicemail, EECA location];

o Email: [EECA Website, LensCrafters Customer Service Center];

o Letter: [EECA Location/Office, LensCrafters Service Center, Luxottica Executive Office]

The patient file is [attached/not attached].

Details of investigation and any resolution provided as of [transmittal date]:

[Describe investigation/resolution efforts]

All grievances received by the Grievance Coordinator will be sent to the Clinical Director within 10 days of receipt.

Please evaluate the grievance for any potential quality issues, and provide recommendations for corrective action as

necessary. Your response will be required prior to the written response/resolution letter that must be mailed to the patient

within thirty days from the date that the initial complaint was taken.

If you have any questions, please contact the Grievance Coordinator at the address listed below, by telephone (949) 364-

2256 x105, or by email at [email protected].


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REVIEW OF GRIEVANCE/FOLLOW-UP COMPLETION FORM NOTIFICATION LETTER

Dear VISION CARE PROVIDER, You are being sent this letter because your location previously received a grievance. Attached is a Review of Grievance Notification from Dr. Cindy Chiang, EYEXAM of California’s Clinical Director, along with a Grievance Follow up Completion Form. After reviewing Dr. Chiang’s assessment of the grievance and recommendations, please fill out the Grievance Follow up Completion Form outlining the steps that will be taken to implement the recommendations made by Dr. Chiang. If no recommendations were made, state “none”, then simply indicate that you have reviewed the notification, sign it and submit it to both your Senior Eye Care Director (SECD) and the Mission Viejo Corporate Office. You can mail it to the Mission Viejo Corporate Office at 29 The Shops at Mission Viejo, Mission Viejo, CA 92691-6513, or fax it to (513) 492-4959. Sincerely, Kathy Cook Grievance Coordinator Enclosures

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RECEIPT OF GRIEVANCE NOTIFICATION TEMPLATE

To: Kathy Cook, Grievance Coordinator [Name] O.D., Senior Eye Care Director, Region ___ [Name] VISION CARE PROVIDER, EYEXAM of CA # ___ [Name] O.D. Provider From: Cindy Chiang, O.D., Clinical Director Date: [Date] Re: Review of Grievance [Patient Name]

This is to notify you that I have received your transmittal and I have evaluated the grievance for potential quality issues. My assessment of the issue is as follows: Primary grievance category presented: [Identify/confirm primary grievance] Secondary grievance categorie(s) presented: [Identify/confirm secondary grievance(s)] Upon further review, additional grievance category recommendations:

___G1 Doctor/Professionalism * ___G9 CL Release ___G17a Access/Office ___G2 Eye Exam * ___G10 Membership ___G17b Access/Appointment ___G3 Prescription* ___G11 Distribution ___G17c Access/Urgent ___G4 Service/Associate ___G12 Product ___G17d Access/Emergent ___G5 Refund ___G13 CL Prescription* ___G18 Appeals ___G6 Coupon/3

rd Party ___G14 Pricing ___G19 Denials

___G7 Insurance Billing ___G15 Clinical Issues* ___G20 Expedited ___G8 CL Replacement ___G16 Miscellaneous ___G21 LAP

*Additional Sub Codes: *G1- Doctor/Professionalism: complaints related to the doctor’s behavior, service, clinical conduct, performance and practice

Sub codes:

G1-a Doctor acted unethically or unprofessionally.



G1-d Doctor refused to see last appointment of the day due to leaving.

G1- e Doctor unfamiliar with how the ancillary equipment and/or testing





G1-j Doctor communicated possible diagnosis in a way that caused undue fear..

G1-k Doctor unfamiliar with exam equipment.

G1-l Doctor did not appropriately answer patient’s questions/concerns.

*G2-Eye Exam: Complaints related to any component of the pretest, exam, CL evaluation or ancillary services.

Sub codes:

G2-a Associate failed to inform patient of any additional pricing for ancillary services.

G2-b Associate seemed to be unfamiliar with the pretest equipment.


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G2-d Patient was not given appropriate instruction or time when learning to insert/remove new contact lens.


G2-f Patient felt that the equipment or exam/pretest room was dirty.



*G3- Prescription: Complaints related to any aspect of the spectacle prescription




G3-d Optician did not take the adequate time to check patient’s glasses to ensure they were able to see and fit correctly


G3-f Issues the patient may have had with their eyewear


*G13- CL Prescription: Complaints related to any aspect of the contact lens prescription

Sub codes:




G13-d Can’t get a convenient appointment to see the doctor for a CL F/U appointment.


G13-f Patient upset that they have to come back in for a f/u appointment.

G13-g Patient has not been taught how to insert and remove CLs.

G14-h Pricing: Complaints related to the fess charged for an eye exam/membership, office visit, contact lens fitting, ancillary services and contacts G15- Clinical Issues: Complaints concerning possible medical quality of care issues, patient incidents involving product, therapeutic/diagnostic agents, solutions, exam equipment, etc.

Sub Categories: G15-a Patient contracted infection






Investigation/determination of potential quality issue: [Identify potential clinical/quality issue, assessment]

Results of clinical review: [Describe results of clinical/quality review] Recommended quality issues follow up: [List any recommendations for corrective action] Recommendations for follow up of primary/secondary grievance: [Identify primary and secondary grievance categorie(s) along with recommended action/follow up]. Additional assessment or recommendations upon review of patient grievance file/chart: [Describe any additional assessment or recommendation from review of patient chart not previously identified]. Please provide written verification within 30 days of the date of this notification, that the above recommendations have been implemented or reviewed and submit to the Mission Viejo Corporate office. If you have any questions, please contact the Clinical Director at the address listed below, by telephone 714-225-5612, or by email at [email protected].


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GRIEVANCE FOLLOW-UP COMPLETION/CORRECTIVE ACTION NOTIFICATION TEMPLATE

To: Cindy Chiang, O.D., Clinical Director Kathy Cook, Grievance Coordinator From: ____________________________ Senior Eye Care Director, Region_____, or ____________________________ VISION CARE PROVIDER, Location: ______ Re: Confirmation/Completion of Clinical Director’s Recommendations for Follow-up/ Corrective Action Patient:_____________________________________________________________

Please identify and describe the Clinical Director’s recommended action/follow up towards resolution of grievance/quality issue:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please identify steps taken to implement the Clinical Director’s recommendations or provide follow up/confirmation that the Clinical Director’s recommendations have been reviewed (time frame, date completed/reviewed): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SECD/Provider’s Signature __________________________________________ Date __________

Date Transmitted to Grievance Coordinator__________ Please fax the completed form back to (513) 492-4959 or email it to [email protected]. If you have any questions, please contact the Grievance Coordinator at the address listed below, by telephone at (949) 364-2256 x105, or at the above email.


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COMMUNICATION OF EECA’S MEMBER GRIEVANCE MEMO

To: LensCrafters California Store Managers cc: Dana Nakagawa SECD, RDEs, LensCrafters RVP, RDOs, and LensCrafters Customer Service From: Eliot Grossman Date: May 20, 2011 Re: Communication of EYEXAM of California Member Grievances

This is an important reminder to all California LensCrafters Store General Managers, California Field, and LensCrafters Customer Service personnel that EYEXAM member grievances need to be communicated to EYEXAM of California immediately upon receipt. California law requires that EYEXAM send a written acknowledgement to all members who submit grievances (complaints) or other inquiries regarding member services or clinical care within five calendar days. A recent audit by the California Department of Managed Health care raised concerns that customer complaints or other inquiries submitted to LensCrafters, either directly or through the customer service website or call center, may also concern patient care issues that EYEXAM must respond to. The Department directed EYEXAM to review and improve its grievance communication processes with LensCrafters in order to ensure that EYEXAM members receive timely and appropriate responses to all complaints or other inquiries. If a store, field manager or customer service representative receives a customer or patient complaint or inquiry having to do in whole or in part with services provided by EYEXAM, and the complaint or inquiry is not resolved at the store level, the complaint or inquiry should be forwarded directly to the EYEXAM Grievance Coordinator. The Grievance Coordinator can be reached at the EYEXAM of California office at 949-364-2256 ext.105, the Grievance Line at 888-439-3392, by fax at 513-492-4959 or by email: [email protected]. EYEXAM appreciates everyone’s attention to this important matter. Please direct any questions to Dr. Dana Nakagawa, Dr. Janet Kim Senior Director(s) of Eye Care, or Kathy Cook, Grievance Coordinator.


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FREEDOM OF OPTOMETRIC PROFESSIONAL JUDGMENT MEMO

To: Managing Optometrists Cc: Andrea Kane, Dana Nakagawa, and EYEXAM RDEs From: Eliot Grossman, President EYEXAM of California Date: April 2, 2012 Subject: Freedom of Optometric Professional Judgment

This reaffirms EYEXAM of California’s longstanding policy confirming the right and obligation of all EYEXAM optometrists to exercise independent professional judgment and medical decision making for the benefit of each individual patient. LensCrafters, based on its own longstanding commitment to the optometrist’s freedom of professional judgment, has adopted its own version of this policy. At EYEXAM of California, the optometrist's primary duties and responsibilities are to provide optometric care appropriate to the needs of each patient, in accordance with state law and the policies and procedures established by the EYEXAM Quality Assurance Committee. Optometrists employed by EYEXAM of California are expected to render all optometric services required by the laws of the State of California and the rules of the California State Board of Optometry. EYEXAM optometrists are also expected to provide patient education and care in accordance with the policies and procedures of EYEXAM of California. These include the Evidence of Coverage and the official protocols and practice standards adopted by the EYEXAM Quality Assurance Committee, as may be amended from time to time. EYEXAM optometrists are expected to perform their duties with the highest standard of professional care and responsibility. At the same time, EYEXAM optometrists are expected and encouraged to work together with LensCrafters associates to serve the needs of patients and customers. EYEXAM optometrists are not responsible, and not accountable, for LensCrafters sales. Management and non-optometrist associates of LensCrafters, Inc. and EYEXAM of California, Inc. are prohibited by company policy from engaging in conduct designed to influence medical decisions of optometrists for fiscal or administrative reasons. There will be no tolerance of any communication or activity that would have a negative impact upon quality of care, independent medical judgment, professional ethics or integrity. Persons who violate this policy are subject to disciplinary action, up to and including termination of employment. In accordance with the Open Door Policy, it is the right and responsibility of the EYEXAM optometrist to report any conduct proscribed by this policy to his or her immediate supervisor, or as otherwise permitted under Open Door. If the manager is the offending party, or the optometrist is not comfortable reporting the conduct to their manager, the optometrist may report the conduct to their manager’s supervisor, to the Associate Relations Call Center, or to the Business Abuse and Compliance Helpline. EYEXAM optometrists may also direct concerns or complaints regarding interference with medical decision making and related issues through their regional representative to the EYEXAM Quality Assurance Committee. Those individuals will be responsible to bring the matter to the attention of the Quality Assurance Committee, and such discussions will be documented in the minutes of the Committee meetings. Upon receipt of such information, the Quality Assurance Committee will report promptly in writing to the EYEXAM President, for further action as necessary. The result of any action taken by the Committee or the President shall be reported to the complaining optometrist, and to the full Committee.

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INTERNAL CHART AUDIT FORM

COLLECTION OF PATIENT INFORMATION MEMO

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To All EYEXAM of California Optometrists and Associates

From: Joanna Chu , O.D., Clinical Director Quality Assurance Committee

Date: September 15, 2010

Re: Collection of Patient Information

The EYEXAM of California Quality Assurance Committee wishes to remind everyone to help patients fully complete the Patient Information portion of the Examination Form. In addition to collecting the patient's medical history, it is important to collect the following information:

1. Personal Information- including patient name, address, gender and date of birth. 2. Telephone Number(s).

3. Language Preference and need for interpreter assistance, if any.

4. Race 5. Employer and Insurance information, as applicable.

6. Interest in looking at eyeglasses at LensCrafters.

If a patient leaves any of the above questions blank, the pre-testing associate has the obligation to inquire

of the patient and document the responses appropriately on the Examination Form. The words "not

applicable" or "N/A" should be written if any question does not apply to the patient. For example, the patient is not employed or does not have insurance. The word "decline" should be written when a patient

does not wish to answer a particular question, The word "unknown" should be written if a patient is unable to answer a question. For example, the patient does not know the address of their employer. Please refer to the Language Assistance Program Manual for tips on having effective conversations with enrollees who

require language assistance. These can be found in section 4 under "Tips for Working with LEP Members", and "Tips for Communicating across Language Barriers". Managing optometrists should audit the charts at their offices to ensure that this portion of the Examination Form is completed consistently.

The Regional Directors of Eyecare will score the subjective category of the chart as a "I" when any of the above questions are left blank during the quarterly audits. A "1" indicates that the history portion is unacceptable and will require the preparation and implementation of the Follow up Action Plan. For more information regarding the internal chart audit process, please refer to Section 3.2 of the Doctor's Manual.

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QUALITY ASSURANCE FOLLOW-UP ACTION PLAN FORM

Quality Assurance Follow Up Action Plan VISION CARE PROVIDER:__________________________________________ Office Location:___________ Please state the issue to be addressed:

Accessibility Internal Audit

Grievances External Audit M.D. Referral Other_____________________________________

After Hours Voice Mail

Identify and briefly describe the issue to be addressed. ___________________________________________________________________________________________________

___________________________________________________________________________________________________

__________________________________________________________________

Please discuss the corrective action you/your team is taking to eliminate this concern. Include any associate training, who will be involved, and the time frame you will need to accomplish your resolution. ___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Provider Signature_______________________________________________ Date______________________ SECD Comments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date Transmitted to Clinical Director _______ SECD Signature ____________________________________ Received by Clinical Director__________________________________ Date ______ EEM09 (9/06) WHITE- DOCTOR CANARY- SECD PINK- CLINICAL DIRECTOR

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EXTERNAL CHART AUDIT FORM

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LOSS OF CONSCIOUSNESS AND ANAPHYLACTIC SHOCK I. Loss of Consciousness A. If a patient loses consciousness, determine the level of responsiveness

1. If the patient is unresponsive Call 911 Monitor breathing, pulse, and blood pressure, and check for verbal responsiveness If there is no detectable breathing and pulse, a CPR certified associate should begin to

perform CPR 2. If the patient is vomiting or has the tendency to vomit

Place them on their side or face down 3. If the patient regains consciousness within seconds to minutes

A cold towel may be comfortable and helpful to the patient Monitor vital signs Observe in the office for 15-30 minutes

B. When to discharge a patient 1. If the patient regains consciousness within seconds to minutes, regains normal vital signs, and

appears stable for 15-30 minutes Advise the patient to see a physician for evaluation Tell the patient the medications or procedures that may have induced the episode

2. After emergency medical personnel arrive for evaluation and provide clearance C. Document the episode in the chart and with an incident report form

1. The medications or procedures that may have induced the episode 2. Vital signs during the episode 3. Whether the patient left the office with advice to see a physician 4. Whether the patient was taken care of by emergency medical personnel 5. Any other care given to the patient

II. Anaphylactic Shock A. Anaphylactic shock: a severe systemic allergic reaction with many possible triggers

a. Signs may include i. Skin: itching, flushing, hives, swelling

ii. Eyes: itching, tearing, redness, swelling of the skin around the eyes iii. Nose and mouth: sneezing, runny nose, nasal congestion, swelling of the tongue,

metallic taste iv. Lungs and throat: difficulty breathing, coughing, chest tightness, throat swelling or

itching, hoarseness, change in voice, sensation of choking v. Heart and circulation: dizziness, weakness, fainting, rapid/slow/irregular heart rate,

low blood pressure vi. Digestive system: nausea, vomiting, abdominal cramps, diarrhea

vii. Nervous system: anxiety, confusion, apprehension b. Promptly remove the inciting trigger when possible

Sources

Anaphylaxis by Pamela W. Ewan: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113119

Patient education: Anaphylaxis symptoms and diagnosis by John M. Kelso, MD: https://www.uptodate.com/contents/anaphylaxis-symptoms-and-diagnosis-beyond-the-basics

Patient education: Anaphylaxis treatment and prevention of recurrences by John M. Kelso, MD: https://www.uptodate.com/contents/anaphylaxis-treatment-and-prevention-of-recurrences-beyond-the-basics

Anaphylaxis: Emergency treatment by Ronna L. Campbell, MD, PhD & John M. Kelso, MD: https://www.uptodate.com/contents/anaphylaxis-emergency-treatment

Rev. 9/18

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113119

https://www.uptodate.com/contents/anaphylaxis-symptoms-and-diagnosis-beyond-the-basics

https://www.uptodate.com/contents/anaphylaxis-symptoms-and-diagnosis-beyond-the-basics

https://www.uptodate.com/contents/anaphylaxis-treatment-and-prevention-of-recurrences-beyond-the-basics

https://www.uptodate.com/contents/anaphylaxis-emergency-treatment

https://www.uptodate.com/contents/anaphylaxis-emergency-treatment

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PHYSICIAN REFERRAL FOLLOW-UP LOG OFFICE #/ NAME ______________________________________

DATE PATIENT NAME REFERRED TO FOLLOW-UP DUE

PHONE DATE/ INIT

LETTER DATE/ INITIALS

NOTES INIT.

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PHYSICIAN REFERRAL FORM

Patient Name Referred to Doctor

Address Address

Phone (H) (W) Phone

Appointment Date/Time

Reason for Referral

Referred by: (Please print name)

OFFICE PHONE: Medicare UPIN #:

The reason I am being referred to another doctor as indicated on this form has been discussed with me. I understand it is my

responsibility to keep the appointment. If I am unable to keep said appointment, it is my responsibility to reschedule directly with the doctor’s office. I realize that this may result in a longer wait for the appointment.

Patient/Guardian Signature: ____________________________________________ Date: ________________

Patient Name (Please Print) __________________________________________ Date of Exam: __________

Results of Exam/ Treatment Provided:

Follow-Up Required:

Physician Signature:__________________________________________ Date: __________________

Physician Name: (Please Print): __________________________________________

Note to Physician: Complete form, retain white copy and return yellow copy to referring doctor (originating Doctor)

URGENT Must be scheduled by _________________

Rx & VA: Add FAR NEAR OD 20/ 20/ OS 20/ 20/

TO BE COMPLETED BY THE PHYSICIAN (PLEASE PRINT)

WHITE – Physician YELLOW – Patient File (originating Doctor) PINK – Office Copy (originating Doctor)

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PHYSICIAN REFERRAL FOLLOW-UP LETTER

Date ______________ Dear ____________________________: You were seen in our office, located at _________________________________________ on ______________________________________ for a complete eye examination. During the course of the examination, I had advised you to seek a medical eye consultation. You were referred to ____________________________________________, whose address is _________________________________________________ and whose telephone number is ___________________________________, or an ophthalmologist of your choice. We have not received notice that you have seen an ophthalmologist and want to remind you that the recommendation was made in your best interest. If we can be of any further assistance in explaining your condition, the reason for the referral or obtaining an appointment, please feel free to call me at (________) ____________________. Sincerely, Vision Care Providers EYEXAM of California, Inc.

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INSTRUCTION FOR FILING SUSPECTED CHILD ABUSE REPORT FORM SS8572 D EFIN IT ION S AN D G EN ERAL INS TRU CTI ON S FO R COMP L ETI ON O F F ORM SS 857 2

All Penal Code (PC) references are located in Article 2.5 of the PC. This article is known as the Child Abuse and Neglect Rep orting Act (CANRA). The

provisions of CANRA may be viewed at http:/www.leginfo.ca.gov/calaw.html (specify "Penal Code' and search for Sections 11164-11174.3). A

mandated reporter must complete and submit the form SS 8572 even if some of the requested information is not known, (PC Section 11167(a),)

I. MANDATED CHILD ABUSE REPORTERS IV.

Mandated child abuse reporters include all those individuals

and entities listed in PC Section 11165.7.

II. TO WHOM REPORTS ARE TO BE MADE ("DESIGNATED AGENCIES")

Reports of suspected child abuse or neglect shall be made by mandated reporters to any police department or sheriff's department (not including a school district police or security department), the county probation department (if designated by the county to receive mandated reports), or the county welfare department. (PC Section 11165.9.)

III. REPORTING RESPONSIBILITIES

Any mandated reporter who has knowledge of observes a child, in his or her professional capacity or within the scope of his or her employment, whom he or she knows or reasonably suspects has been the victim of child abuse or neglect shall report such suspected incident of abuse or neglect to a designated agency immediately or as soon as practically possible by telephone and shall prepare and send a written report thereof within 36 hours of receiving the information concerning the incident, (PC Section 11166(a).)

No mandated reporter who reports a suspected incident of child abuse or neglect shall be held civilly or criminally liable for any report required or authorized by CANRA. Any other person reporting a known or suspected incident of child abuse or neglect shall not incur civil or criminal liability as a result of any report authorized by CANRA unless it can be proven the report was false and the person knew it was false or made the report with reckless disregard of its truth or falsity. (PC Section 11172(a).)

I V . I NST RUC TIO NS

SECTION A - REPORTING PARTY: Enter the mandated reporter's name, title, category (from PC Section 11165.7),

business/agency name. and address, daytime telephone

number, and today's date. Check yes-no whether the mandated

reporter witnessed the incident, The signature area is for either

the mandated reporter or, if the report is telephoned in by the

mandated reporter, the person taking the telephoned report.

E T H N I C I T Y C O D E S

INSTRUCTIONS (Continued)

SECTION B - REPORT NOTIFICATION: Complete the name and

address of the designated agency notified, the date/ time of the

phone call, and the name, title, and telephone number of the official

contacted.

SECTION C - VICTIM (One Report per Victim): Enter the victim's name, address, telephone number, birth date or

approximate age, sex, ethnicity, present location, and, where

applicable, enter the school, class (indicate the teacher's name or

room number), and grade. List the primary language spoken in the

victim's home. Check the appropriate yes-no box to indicate

whether the victim may have a developmental disability or

physical disability and specify any other apparent disability. Check

the appropriate yes-no box to indicate whether the victim is in

foster care, and check the appropriate box to indicate the type of

care if the victim was in out-of-home care. Check the appropriate

box to indicate the type of abuse. List the victim's relationship to

the suspect. Check the appropriate yes-no box to indicate

whether photos of the injuries were taken, Check the appropriate

box to indicate whether the incident resulted in the victim's

death,

SECTION D - INVOLVED PARTIES: Enter the requested

information for: Victim's Siblings, Victim's Parents/ Guardians, and

Suspect. Attach extra sheet(s) if needed (provide the requested

information for each individual on the attached sheet(s)).

SECTION E - INCIDENT INFORMATION: If multiple victims,

indicate the number and submit a form for each victim, Enter

date/time and place of the incident. Provide a narrative of the

incident. Attach extra sheet(s) if needed.

V. DISTRIBUTION

Reporting Party: After completing Form SS 8572, retain the

yellow copy for your records and submit the top three copies to

the designated agency.

Designated Agency: Within 36 flours of receipt of Form SS

8572, send white copy to police or sheriff's department, blue copy to county welfare or probation department, and green copy

to district attorney's office,

1 Alaskan Native 6 Caribbean 11 Guamanian I6 Korean 21 Polynesian 26 White-Armenian

2. American Indian 7 Central American 12 Hawaiian I7 Laotian 22 Samoan 27 White-Central American

3 Asian Indian 8 Chinese 13 Hispanic 18. Mexican 23 South American 28 White-European

4 Black 9 Ethiopian 14 Hmong 19 Other Asian 24 Vietnamese 29 While-Middle Eastern

5 Cambodian 10 Filipino IS Japanese 20 Other Pacific Islander 26 White 30 White-Romanian

http://www.leginfo.ca.gov/calaw.html

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EXAM EQUIPMENT SUPPORT REVISED 3.21.19

EQUIPMENT TYPE SERVICE DESCRIPTION EQUIPMENT DESCRIPTION PROCESS FOR REQUESTING SERVICE OR PARTS PHONE

Auto Refractor (non Clarifye)

ŸBIO * Before submitting a service request, reference the Users Manual for trouble-shooting tips

Exam Chair & Stand 1- If needed, the SM can access the Store Maintenance web portal thru the POS system

Fields Tester 2- Request a new service request

General Exam Lane Cleaning & Calibration LCD Chart (non Clarifye) 3- Select DOCTOR EXAM ROOM or DOCTOR PRETEST ROOM

Exam Chair Re-Upholstery Lensmeter (non Clarifye) 4- Select the type of equipment in need of service or parts

Specific Repairs NCT 5- Select SERVICE or REPLACEMENT PARTS

Replacement Parts Phoroptor (non Clarifye) 6- Key in the MAKE, MODEL and the SERIAL NUMBER of the device

Pretest Table 7- Add a brief description of the problem

Projector 8- Select the appropriate priority (Only select EMERGENCY is unable to complete exams)

Slit Lamp 9- Refresh the request daily to follow the request progress

Stereo Vision Tester

ALL Replace, Upgrade or Add All Exam Equipment Types Submit any requests thru your Regional Manager or your EyeCare Director

VisuPhor® (Digital Phoroptor)

iProfiler® (Auto Refractor / Wavefront) 1- Click on the Support App icon on the CLARIFYE® Tablet

VisuLens® (Auto Lensmeter) 2- Use the on-line form to request service

VisuScreen® (LCD Chart)

RTS-5100 (Digital Phoroptor)

OPD-III (Auto Refractor / Wavefront) 1- Click on the Emergency Support icon on the CLARIFYE® Consultation System

LM-600 (Auto Lensmeter) 2- Use the on-line form to request service

SCR-1600 (LCD Chart)

1- Call OPTOS directly

2- Have the MAKE, MODEL and SERIAL NUMBER handy when calling

Batteries

Bulbs

Diagnostic Lenses

Dr Stools 1- The SM can access CENTRAL PURCHASING (CP) thru the POS web portal

Dust Covers 2- Use the search index to locate the product and article number

Hand Scopes 3- Supplies are generally shipped on a monthly basis

Pharmaceuticals (employed Drs only) 4- Costs are billed to the retail side

Press-On Prisms

Printer Paper

Trial Lens Replacements

EXA

M-R

ELA

TED

ACC

ESSO

RIE

S

Supplies Replenishment of Exam-Related

Accessories

1-877-226-6632

EXAM EQUIPMENT SUPPORT - LENSCRAFTERS

Call For Emergencies

1-513-765-3500

OPT

OS

All Operational Concerns Associated with the

Optos Daytona® Optos Daytona®

1-800-854-3039

Monday - Friday

8:30 am - 5:00 pm ET

CLA

RIF

YE ®

ZEIS

S

CLA

RIF

YE ®

MA

RCO


Clarifye Zeiss Equipment


Clarifye Marco Equipment

CLA

SSIC

AL

EXA

M E

QU

IPM

ENT

(NO

N C

LAR

IFYE

®)

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Section 12: APPENDIX

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ONESIGHT VOUCHER PROGRAM PROCEDURES

The purpose of this memo is to describe the proper procedures for the OneSight Voucher Program examinations and eyewear. OneSight Voucher Programs Throughout the year, doctors and associates from participating Luxottica Retail Stores are encouraged to provide free exam and reduced price eyewear to those in need through the OneSight In-store Voucher program. Vouchers can be given out throughout the year. EYEXAM of California believes that the OneSight program is very important; therefore, at all employed locations, EYEXAM doctors perform OneSight exams in conjunction with the completed OneSight On Site voucher and glasses*. All recipients should already be referred by a 501(c)(3) non-profit organization, such as the Lion’s Club, community agency, school, or church that screens potential recipients for visual and financial needs. On-Site Vouchers OneSight provides all optical brands with OneSight On Site Vouchers to be used in conjunction with local charities. These vouchers are used in your store to assist pre-selected local recipients based on financial and visual needs to choose a free pair of eyeglasses. These vouchers should be kept in the safe and used according to the instructions. How to use the OnSite Voucher

Voucher must be completed before use. The charitable agency should provide recipient with a note or letter on agency stationary with tax

ID number and/or call ahead to introduce recipient. Name, address and tax ID number of the charitable organization should be included on the voucher,

along with the recipient/guardian signature. A manager must sign and date the voucher.

How to Redeem the On-Site Voucher in CIAO 1) Build a customer profile, 2) Select a OneSight frame and place patient in a plastic lens that best suits their vision needs (Single vision or Bifocal) 3) Process the transaction as you normally would in Ciao 4) On the check-out screen, click Add Discount, and then select “1. Add discount code” and enter the global charitable allowance code 547018# ***You can also use global charitable allowance code #547018 for the exam or tender it out under Gift of Sight in the EYEXAM of California CIAO POS terminal. This code is not to be used for One Day (formerly known as Hometown Day) Exams, just for OneSight exams performed during the year along with completed voucher.

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ONESIGHT VOUCHER PROGRAM PROCEDURES (cont.)

Remember to staple a copy of the receipt to the WHITE On Site voucher copy and place in DCR/EOD envelope. Staple the letter from the charitable organization to the YELLOW On Site voucher copy in the book and make sure to return the On Site voucher book to a secure location. When the voucher book is complete or it is the end of the year, please mail the USED book to: Luxottica Retail Dock 5 9936 International Blvd. Cincinnati, OH 45246 ATTN: OneSight Supplies Additional voucher books can be re-ordered through Central Purchasing (use CP #3001044). Please refer to your OneSight Captain should you have any questions, or you can call (513) 765-6739 for general information. For questions concerning store vouchers call (513) 765-3081. *Sublease doctors are encouraged to participate in the OneSight eye exam voucher program at their discretion. EYEXAM of California does not reimburse sublease doctors for these exams.

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Section 12 cont.: PATIENT HANDOUTS

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BLEPHARITIS HANDOUT

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CATARACTS HANDOUT

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DIABETIC RETINOPATHY HANDOUT

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DRY EYE HANDOUT

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FLASHES, FLOATERS & VITREOUS DETACHMENT HANDOUT

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GLAUCOMA HANDOUT

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MACULAR DEGENERATION HANDOUT

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If you are at risk of developing macular degeneration, even though you are not aware of any visual symptoms, you will be advised to maintain regular follow-up examinations. Use the simple vision check on this sheet to screen for early signs of macular degeneration. If you are a candidate for possible treatment or at risk for wet macular degeneration, your eye doctor may refer you to a specialist for further testing and evaluation.

Directions for using chart: Hold the card 12 inches (30cm) from your eyes. Wear your reading glasses if needed for reading. Cover one eye. While focusing on the dot in the center of the grid, ask yourself: 1. Is the center spot visible? 2. Am I able to see the corners and slides of the square? 3. Do I see any wavy lines? 4. Are there any holes, missing or blurred areas?

5. If the lines of the grid do no look straight or any areas appear to be consistently missing, blurred or

distorted while looking at the central dot, please contact our office.

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PEDIATRIC EYE EXAMINATION GUIDELINES

Guideline for Pediatric Eye and Vision Examination A comprehensive vision examination for children may be modified from protocol based on a patient’s ability to subjectively respond. When a test is administered and the patient is unable to complete the test, documentation on the chart should include a statement of explanation. For example, "78D/90D Fundus assessment: attempted but unable due to poor fixation and attention." Another example, "IOP NCT: attempted, patient did not sit still; unable. Tactile pressure appears normal." If a standard test is not attempted, documentation on the chart should include a statement of explanation. For example, "Visual Acuity: patient unable to understand tumbling E, and does not know letters/numbers." The goal for vision exams for infants and toddlers is to use any and all objective and subjective tests available in office to assess vision and ocular health issues. Based on the evaluation, if the child needs additional or more specialized testing, a referral to a pediatric optometrist or ophthalmologist is appropriate. The rest of this section is a reference for clinical testing that may be used to support a pediatric vision evaluation. A pediatric evaluation kit is available from the Mission Viejo Home Office. Please call Kathy Cook at (949)364-2256 x 105 four business days prior to the patient’s appointment.

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Reference for Pediatric Eye and Vision Examination

Infants & Toddlers Preschool Children School-Age Children

Age Range Birth to 2 years * 3 to 5 years 6 to 18 years

General Considerations

Rely on objective findings

Perform tests rapidly

Toys and bright lights may be needed as fixation targets and change target frequently

Rely on objective

Limited use of subjective techniques

Use the most sophisticated test that a child is capable of

Age-appropriate modifications to instructions given & targets may be required

Examples of Early Detection & Preventions

Strabismus

Amblyopia

Significant refractive error

Neoplasm

Neuromuscular Disorder

Vascular anomaly

Traumatic damage

Child Abuse/Shaken Baby Syndrome

Glaucoma

Nystagmus

Squinting/photophobia

Head Tilt

Conjunctivitis

Persistent tearing

Leukocoria

Retinoblastoma

Cataract

Strabismus

Amblyopia


Visual perceptual dysfunction

Learning related vision problems

Nystagmus


Head Tilt

Conjunctivitis

Cataract

Strabismus

Amblyopia


Visual perceptual dysfunction

Learning related vision problems

Behavior, language, or social development

Conjunctivitis


Head Tilt

Cataract

Risk Factors for Development of Eye & Vision Problems

Prematurity, low birth weight, oxygen at birth, grade lll or lV intraventricular hemorrhage

Family hx of blindness, retinoblastoma, congenital cataracts, metabolic or genetic disease

Infection of mother during pregnancy (rubella, toxoplasmosis, venereal disease, herpes, cytomegalovirus, HIV)

Substance abuse by mother during pregnancy

Difficult labor, associated w/fetal distress or low Apgar scores

CNS dysfunction as evidenced by developmental delay, cerebral palsy, dysmorphic features, seizures, or hydrocephalus

Patient History Prenatal, perinatal, & postnatal health hx

Family eye & medical hx Developmental hx Chief Complaint

Visual & ocular hx

Prenatal, perinatal, & postnatal health hx

Family eye & medical hx

Development hx

Chief Complaint

Visual & ocular hx

Prenatal, perinatal, & postnatal health hx

Family eye & medical hx

Development hx

School performance hx

Chief Complaint

Visual Acuity Fixation preference tests

Preferential looking visual acuity test/Teller Acuity Cards

Optokinetic Drum

VEP (if suspect no vision present in eye)

Lea Symbols chart

Broken wheel acuity cards

HOTV test

Tumbling E

Numbers Chart

Allen Chart/Cards

Snellen acuity chart

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Refraction Cycloplegic retinscopy

Near (Mohindra) retinoscopy (less reliable)

Static retinoscopy

Cycloplegic retinoscopy Static retinoscopy Cycloplegic retinoscopy Subjective refraction

Indications for Cyclopegia

Large difference between retinoscopy and subjective refraction

Reduced acuity after subjective refraction

Any Eso Deviations

Signs and symptoms of hyperopia

Lag on MEM retinscopy

Anisometropia

Poor accommodative skills

Malingering

Diagnostic Pharmaceutical Agents 1 2

Birth to 1 yr.:1 gtt Cycloplentolate HCL 0.5%, 5 min apart; 1 gtt 2.5% phenylephrine

>1 yr. 1gtt Cycloplentolate HCL 1%, 5 min apart; 1gtt 2.5% phenylephrine

Spray mixture of 0.5% Cycloplentolate, 0.5% tropicamide, 2.5% phenylephrine

1 gtt Cycloplentolate 1%, 5 min apart; 1 gtt 2.5% phenylephrine

Spray mixture of 0.5% Cycloplentolate, 0.5% tropicamide, 2.5% phenylephrine

1 gtt Cycloplentolate 1%, 5 min apart; 1 gtt 2.5% phenylephrine

1 gtt Tropicamide 1%, 1 gtt

2.5% phenylephrine

Binocular Vision/Accommodation

Cover test

Direct observation

Hirschberg test

Krimsky test

Bruckner test

Cover test

Near Point of Convergence

Stereopsis (Fly Test)

Fusional Vergence with Prism Bar

Worth 4 Dot

MEM retinoscopy

Cover test

Near Point of Convergence

Stereopsis (Fly Test)

Worth 4 Dot MEM retinoscopy Accommodative amplitude &

facility

Ocular Motility (Modifications: use age-appropriate target periodically during testing, and gently hold child’s head still while

moving target)

Versions Versions

Positive & Negative fusional vergences

Versions

Positive & Negative fusional vergences

Ocular Health Assessment

Anterior segment & adnexa (Use transilluminator with 20D)

Posterior segment

Pupillary responses

VF screening (Confrontations)

IOP when indicated (Digital Pressure)

Color Vision Most important when 3-4 years of age

Color vision higher prevalence in males

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Systemic Health Screening

Juvenile Immune Arthritis

Juvenile DM

Neurological Disorders

Chronic Steroid Use

Other Medication Use

Supplemental Testing

VEP Denver Developmental Screening test

Developmental Test of Visual Motor Integration

Gardner Reversal Frequency Test (directionality)

Developmental Test of Visual Motor Integration

Assessment & Diagnosis

Referral for consultation when appropriate. Some tests may require sedation/anesthesia

Refer for potential visual perceptual dysfunction or learning related vision problems

Refer for consultation with pediatrician, psychologist, Dept. of Special Education when appropriate

Guidelines for Prescribing

For children< 3 years and nonstrabismic, evaluate for stability in refractive error and risk factors for strabismus/amblyopia

For children <3 years and strabismic, prescribe on initial evaluation

For children <3 years, more likely to Rx on initial evaluation

General Rule for Prescribing

Monitor every 3 months the first year of life if there is abnormal degree of refractive error

Closely monitor refractive error until it is stable

Cut cycloplegic hyperopic findings by 1-2 D

Child refraction when beginning school maybe a predictor of what can be expected later in school age years

Duty to Warn Provide polycarbonate lenses to children up to age 18 years unless a waiver is signed

Indications for Referral

Abnormal or asymmetric red reflex

Structural abnormality

Failure to fix and follow (cooperative 6 months infant)

Object to equally cover each eye (after 6 months)

Inability to perform a satisfactory exam



20/50 or worse, or 2 lines of difference b/w the eyes




20/30 or worse, or 2 lines of difference b/w the eyes


Caution with Cyclopentolate

Cyclopentolate is contraindicated in children with CNS disorders, Down syndrome, Angle Closure Glaucoma, Spastic paralysis, or those taking medications that may interact adversely with cyclopentolate.

Common Side Effects: Blurred vision, redness, burning sensation, irritation to the eye, sensitivity to light.

Severe/rare Side Effects: Allergic reactions, changes in behavior, including clumsiness, confusion, difficulty walking, disorientation, hallucinations, hyperactivity, restlessness, seizures, or slurred speech.

Use 1% Tropicamide for children w/CNS disorders

General Caution with Dilation

Do not instill more than 3 sets of drops, unless you are certain that the drops did not get into the eyes.

Always caution parents/guardians/patients the potential side effects of dilation and its expected duration.

*Refer to infantsee.org or covd.org for further evaluation.

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GLOSSARY OF PEDIATRIC PROCEDURES

Allen Chart: A set of nine cards on one of which is a 13 mm Snellen F and on each of the others an acuity test character of approximately equal difficulty depicting very familiar objects for testing preschool children (3-5 yo). Test is done at 20ft with a 20/30 threshold.

Broken Wheel Acuity Cards: Landolt C targets are used. The child is asked to point to the car with the broken wheel. The test is stopped when 2 or less is correct, and the acuity recorded is the highest level at which at least 1/4 correct. The test is performed at 10 ft. Bruckner Test: When both eyes are simultaneously illuminated with the ophthalmoscope beam at a distance of 100 cm, an overall whitening of the red reflex across the entire pupil of one eye indicates strabismus or anisometropic amblyopia. While the absence of a Bruckner reflex is not a good indication of alignment, the presence of a Bruckner reflex is considered a positive result, and is a good indication of strabismus, even of small amounts.

Denver Developmental Screening Test: A screening test for the detection of abnormal development in young children, composed of four sections—personal-social, fine motor adaptive, language, & gross motor skills.

Developmental Test of Visual Motor Integration: The Beery VIVII helps assess the extent to which individuals can integrate their visual and motor abilities, The Short Format and Full Format tests present drawings of geometric forms arranged in order of increasing difficulty that the individual is asked to copy. The Short Format is often used with children ages 2-8 years.

Fixation Preference Testing: The detection of monocular amblyopia by placement of a 10-diopter vertical prism in front of one eye and then occluding each eye in turn during binocular diplopic viewing to observe the promptness of re-fixation by the un-ocluded eye.

Gardner Reversal Frequency Test: Test of directionality.

Hirschberg/Kappa Test: the test for approximating the objective angle of strabismus, in which the position of the reflex of a fixated light source at 50 cm, in line with the observer's eye, is noted on the cornea of the deviating eye. By performing it monocularly, the shift in corneal reflex position indicates the strabismus.

HOTV Test: A letter-matching test involving these 4 letters tested at 10ft. Good for child at 3-5 years of age.

Krimsky Test: A method for determining the objective angle of strabismus in which the examiner, with his eye directly above a light source fixated by the subject, observe the position of the corneal reflexes. Prisms are placed before the deviating eye until reflex appears to occupy the same relative position as that in the fixating eye.

Lea Symbols Chart: Consisting of four optotypes (circle, square, apple, house), children have to find a matching block or point to the shape that matches the target presented. Good for 18 months to 4 years of age.

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Monocular Estimation Method (MEM) Retinoscopy: Measurement of the lag of accommodation by the selection and very brief insertion of a trial lens before a patient's eye while he is reading, binocularly at this approximately habitual reading distance. The letters around the small aperture of a card mounted in the plane of a retinoscope peephole through which the sweep of the light reflex is simultaneously observed to be neutralized. Near Retinoscopy (Mohindra): Retinoscopy performed on infants or very young children in a darkened room at 50 cm with the one eye fixating the retinscope light. Test done only on child under 3 years of age. Subtract 1.25 diopters from gross finding.

Optokinetic Drum: An objective test for visual acuity, in which the threshold for optokinetic nystagmus is determined.

Preferential Looking Acuity: A pychophysicial measuring technique employing the tendency of an infant to fixate preferentially a stimulus having one or another variable visible attributes such as shape, color, clarity, or resolvability, with relative frequency of fixations in response to varied stimulus values providing a determination of the stimulus threshold.

Static (Distance, non-cycloplegic) Retinoscopy: Retinoscopy performed while the patient fixates a target at infinity or with accommodation otherwise relaxed.

Teller Acuity Cards: The set of seventeen cards measure an infant or child's ability to resolve black and white striped patterns printed on the cards using Preferential Looking

Tumbling E Chart: A test for determining the visual acuity of children or illiterates in which the subject is given an E to hold and orient in the same direction as the indicated E on a tumbling E chart. Synonym--Illiterate E Test.

Vergence: A disjunctive rotational movement of the eyes such that the points of reference on the globes move in opposite directions, as in convergence.

Versions: A conjugate movement of the eyes such that their meridians or lines of reference move in the same direction,

Visually Evoked Potentials: The electrical discharge that occurs in the visual cortex in response to visual stimuli as recorded through electrodes on the scalp at the back of the head.

Worth's Four Dot: A test for binocular vision, in which four dots, one white, one red, and two green on a black background, are viewed through complementary red and green colored filters, such that one eye sees the red and the white clot and the other eye sees the two green dots and the white clot. Four dots seen in the pattern of the original formation indicate normal binocular vision, five dots binocular vision without fusion, and two red dots only, or three green dots only, suppression of one eye.

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KERATOCONUS GUIDELINES Goal To ensure that our patients are able to obtain all the Keratoconus services and products that they need and desire

General Information According to the National Keratoconus Foundation, keratoconus is a non-inflammatory condition in which the cornea (front part of the eye) progressively thins to form a cone-like bulge resulting in irregular astigmatism. The abnormal shape prevents light and images entering the eye from being focused correctly on the retina, causing distortion and blurred vision. Other symptoms include increased light sensitivity, difficulty driving at night, halo effect around lights and eye strain. Keratoconus occurs in 1 out of every 2,000 people in the general population. Patients are first diagnosed in the late teens or late 20’s and may progress for the next 10-20 years. Each eye may be affected differently. With the FDA approving crosslinking, managing keratoconus for optometrists has changed. It is important to identify as early as possible and prevent progression.

Levels of treatment Level 1 – Referral/Co-management with an ophthalmologist

1. Cross-linking (approved in April 2016)

a. Cross linking is a minimally invasive procedure that strengthens the stroma by

establishing new bonds between the collagen fibers

b. FDA approved Avedro, Inc. in May 2016 as the first-in-class therapeutic treatment for

keratoconus with its Photrexa and KXL system

c. It is recommended for all progressive keratoconic patients as soon as possible

2. Corneal intacs (approved in 2014)

a. Intacs are thin plastic, semi-circular rings inserted into the mid layer of the cornea,

which flattens the cornea and changes the shape and location of the cone

b. The goal of intacs are to improve contact lens tolerance and reduce astigmatism

3. Corneal transplant

Level 2 – Basic Refraction Options 1. Glasses – educate patient on how prescription can change depending on progression

2. Soft contacts – Available toric contact lenses

a. Proclear Toric XR

b. Frequency 55 Toric XR

c. Vertex Toric XR

d. Biofinity Toric XR

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Level 3 – Advanced CL fitting 1. RGPS recommendations:

a. Apex lens (X-cel) – MSRP $190/lens ($76/lens wholesale price)

i. Aspheric thin lens design to minimize apical interaction

ii. X-cel consultation will be able to provide clinicians with a lens with the patient’s

K’s and prescription

b. Rose K lens (Art Optical) – MSRP $168/lens ($67/lens wholesale price)

i. Most widely used keratoconus lens used in the world

ii. Offer enhanced comfort due to reduced lens mass

iii. Fitting set has a $25 usage fee (non-refundable)

iv. Note: prices for the lens goes up with warranty or degree of astigmatism

2. Scleral lens recommendations:

a. Atlantis (X-cel) – MSRP $313/lens ($125/lens wholesale price)

i. Mini-scleral that has a diameter between 15.00 and 16.50

ii. X-cel rents out a diagnostic set for $600, which will be credited back to the

account once returned

b. Ampleye (Art Optical) – MSRP $300 ($120/lens wholesale price)

i. Fitting by patient condition and not K-readings

ii. Fitting set is available for purchase for $200 (non-refundable)

iii. Note: prices for the lens goes up with warranty or degree of astigmatism

Patient and Doctor Resources 1. National Keratoconus Foundation – www.nkfc.org

2. Scleral Lens Education Society – www.sclerallens.org

3. A Guide to Scleral Lens Fitting –

http://commons.pacificu.edu/cgi/viewcontent.cgi?article=1003&context=mono

4. Request for Medically Necessary Form – refer to the Provider’s manual section 8

http://www.nkfc.org/

http://www.sclerallens.org/

http://commons.pacificu.edu/cgi/viewcontent.cgi?article=1003&context=mono

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DRY EYE GUIDELINES Goal To ensure that our patients can obtain all the dry eyes services and products that they need and desire. General Information Dry eye is a multifactorial condition in which the tears are unable to provide adequate lubrication. Symptoms include blurry vision, discomfort, irritation, tearing, redness, glare and contact lens intolerance. If left untreated, corneal pain, ulcers, scars or even blindness can occur. According to the National Eye Institute, nearly five million Americans over 50 are estimated to have dry eye. Women are a 2:1 higher risk of experiencing symptoms than men, especially after menopause. In addition, millions experience a mild case of dry eye. Causes of Dry Eye There are 2 main types of dry eye:

1. Aqueous tear deficiency – disorder in which the lacrimal glands are not producing enough of the

water component of the tears

2. Evaporative tear deficiency – disorder in which the Meibomian glands are inflamed and are not

producing enough lipid component of the tears

Distinguish between chronic vs acute: 1. Chronic – 1 month or longer

2. Acute – less than 1 month

Other causes of dry eye 1. Inflammation of the anterior segment

2. Thyroid disease and other systemic inflammatory and autoimmune disorders

3. Eyelid issues

a. Ectropion – outward turning of the eyelid

b. Entropion – inward turning of the eyelid

c. Lagophthalmos – when the lids do not completely close

4. Cosmetic surgery and refractive surgery

5. Medications

a. Antihistamines

b. Tricyclic antidepressants

c. Selective serotonin reuptake inhibitors

d. Diuretics

e. Beta-blockers

f. Anticholinergics

g. Anxiolytics

h. Antipsychotics

i. Systemic retinoids (i.e. isotretinoin)

6. Contact lenses

7. Vitamin A deficiency

8. Environmental factors – i.e. wind, humidity, air conditioning, travel

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Diagnostic Testing1 1. Aqueous tear deficiency

a. TBUT – less than 10 seconds

b. Ocular surface dye staining – corneal and bulbar conjunctival staining is typical

c. Aqueous tear production and clearance (Schirmer test) – 5mm or less for Schirmer with

anesthesia considered abnormal

d. Tear osmolarity – increased

2. Evaporative tear deficiency

a. TBUT – less than 10 seconds

b. Ocular surface dye staining – staining of inferior cornea and bulbar conjunctiva is typical

c. Tear osmolarity – increased

3. Different types of ocular staining2

a. Fluorescein – used for corneal epithelial evaluation

i. Also used for TBUT testing

ii. Not as commonly used for conjunctival evaluation due to the dye’s presence in

the tear film

b. Rose Bengal – used for ocular conditions such as keratoconjunctivis sicca, herpetic

epithelial dendrites, superficial punctate keratitis, and Meibomian gland dysfunction

i. Not considered a “vital dye” because it stains dead cells and healthy living cells

ii. Known to have an intrinsic cellular toxicity towards bacteria and viruses, which

can complicate the diagnosis of the ocular pathology

iii. CAUTION: known to cause stinging upon instillation and staining on clothing

c. Lissamine green – used for corneal and conjunctival evaluation

i. Stains only damaged cells

ii. Useful for patients with red eyes since the green dye will stand out

iii. No discomfort known upon instillation

Levels of Treatment Level 1

1. Supplements

a. Fish oil (Omega 3)

i. Available in liquid and capsule form (1,000mg daily)

ii. i.e. Theratears Nutrition, Biotears and HydroEye Nordic Naturals

iii. CAUTION: recommend the patient to take fish oil with food – fish oil can cause

upset stomachs and/or diarrhea in high dosage

iv. CAUTION: long term use of fish oil can cause Vitamin E deficiency

b. Flaxseed oil

i. Available in liquid and capsule form – it contains omega 3 fatty acids that are

used to protect cell membranes

ii. i.e. Theratears Nutrition, Dry Eye Formula and Tears Again Hydrate

iii. CAUTION: Be careful with patients who are on blood thinners including aspirin –

flaxseed oil and fish oil can increase the risk of bleeding

2. Over the counter artificial tears

a. Cellulose-based artificial tears – drops that add volume to the aqueous layer of tears

i. i.e. Refresh Tears, Refresh Liquigel, Tears Naturale and Genteal

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b. Glycerin-based artificial tears – drops that increase the spreading of tears, acting on

aqueous and mucin layers of tears

i. i.e. Refresh Optive, Blink Tears, Oasis Tears and Systane Ultra

c. Emulsion artificial tears – drops that help replace the lipid layer of the tear film and

prevent evaporation

i. i.e. Systane Balance, Refresh Endurua and Soothe XP

d. Preservative-free artificial tears – drops that are utilized for sensitive eyes including

individuals who have acute keratitis or have gone through surgery

i. Recommended for patients who use artificial tears more than 4-6 times per day

ii. i.e. Oasis Tears, Systane Preservative Free, Refresh Free, Blink Free and Tears

Naturale

e. FreshKote – artificial tear that involves all three layers of the tears to stabilize tear film

and to prevent evaporation

3. Modify environment

a. Fans used while sleeping, open window causing desiccation (consider sleep mask)

b. Consider humidifier

4. Other Remedies

a. Warm compresses

b. Ocusoft lid cleanser

c. Bruder Mask – clinically proven to treat chronic dry eye, MGD and blepharitis

i. Directions: Microwave for 20-25 seconds and apply for 10 minutes

ii. Helps stabilize tear film, improve gland function and slow tear evaporation

d. Side shields on glasses

Level 2 1. Prescription medication

a. Restasis (Cyclosporone Ophthalmic Suspension 0.05%) – an anti-inflammatory that

increases basal tear production

i. Directions: Use a drop twice a day – 12 hours apart

ii. Used for tear insufficiency

iii. Studies show symptoms improve within 3-6 months

iv. My Tears, My Rewards is a manufacturer program that provides patients instant

savings

v. CAUTION: contraindicated in patients with active or recurrent ocular infection

b. Xiidra (Liftegrast Ophthalmic Solution 5%) – newly FDA approved for all dry eye patients

i. Directions: Use a drop twice a day – 12 hours apart

ii. Studies show symptoms improve within 2 weeks

iii. CAUTION: not known to be safe for anyone under 17 years of age, pregnant or

anyone nursing

c. Avenova with Neutrox – lid cleanser spray

i. Directions: Apply 2-3 sprays of Avenova onto a cotton round/oval twice a day

ii. Uses hypochlorus acid (part of the body’s natural defense mechanism against

pathogens, normally released by neutrophil cells)

iii. Used for dry eyes secondary to MGD and blepharitis

iv. Studies show symptoms improve within 2 weeks

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v. Rebate available on the manufacturer website

d. Lacrisert (Hydroxypropyl Cellulose Ophthalmic Insert) – preservative-free sustained

release ophthalmic insert that stabilizes and thickens pre-corneal tear film to improve

TBUT

i. Directions: Insert in each eye once daily

ii. Used for patients with moderate dry eye syndrome, including patients with

exposure keratitis, recurrent corneal erosions and decreased corneal sensitivity

iii. CAUTION: improper placement can lead to corneal abrasion

e. Mucomyst (N-Acetylcysteine Solution) – mucolytic agents that digest mucoproteins

i. Directions: Use 5 or 10% four times a day

ii. Useful for patients with filamentary keratitis and/or patients with mucous

discharge and/or plaques

iii. Requires a compounding pharmacy

iv. CAUTION: topical solution is produced without a preservative, so any unused

portion should be discarded within 30 days

f. Steroids – anti-inflammatory agents that inhibit inflammatory mediators

i. Available topical steroids

1. Dexamethasone – strong topical steroid that doesn’t penetrate the

cornea – strong side effects profile

2. Prednisolone – strong topical steroid that penetrates the cornea

3. Fluoromethalone and Lotemax – less potent steroids with a better

safety profile

ii. An effective combination therapy consists of Lotemax QID for 2 weeks then

taper to BID, where Restasis BID is added – after 60 days, stop the Lotemax and

continue the Restasis BID

iii. CAUTION: long term usage can lead to corneal infection, glaucoma and/or

cataracts

g. NSAIDs – agents that block cyclooxygenase, which prohibits prostaglandins from causing

inflammation

i. Available topical NSAIDs: Bromfenac (Xibrom), Keterolac (Acular), or Nepafenac

(Nevanac)

ii. Used in patients with evaporative dry eyes or patients with MGD

iii. CAUTION: NSAIDs are known to cause corneal melts – especially in generic

agents

h. Topical antibiotics

i. Used in patients with blepharitis or MGD

ii. Available topical antibiotics

1. Erythromycin ointment – apply along eyelid before bed

2. Bacitracin ointment – apply along eyelid before bed

3. Azasite (Azithromycin Ophthalmic Solution 1%) – put one drop on your

finger and rub it along the lid margins twice a day

iii. Antibiotics are usually used 7-10 days to break down the bacteria in the lipid layer

iv. Oral antibiotics

v. Comprehensive treatment secondary to antibiotic effect, anti-inflammatory

effect, and antiangiogenic effect

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vi. Used in patients with posterior blepharitis or patients with rosacea

vii. Available oral antibiotics

1. Doxycycline and Minocycline are the commonly used tetracyclines, with

Doxycycline more prominent to Minocycline secondary to side effects

2. Azithromycin

viii. Dosage depends on severity of the inflammation. An example dosage would be

Doxy 100mg BID x 7 days then QD x 1 month (or as needed)

ix. CAUTION: Doxycycline is known to cause gastritis – patients should take their

medication with food but not dairy. Long term use may result in candida

vaginitis and oral thrush.

x. CAUTION: Avoid sunlight with tetracyclines

Level 3 1. Punctual plugs

a. Biocompatible devices inserted into the inferior puncta to temporarily block tear

drainage

b. Main purpose is to increase retention of tears

c. Two types of punctal plugs

i. Dissolvable, typically made of collagen

1. Lasts 4-7 days

2. Used as trial prior to semi-permanent punctal plugs

3. May also be used in conjunction with topical medications, post

operatively (LASIK/PRK)

ii. Semi-permanent, typically made of silicone

1. Lasts several months to years, unless dislodge

2. 40% of patients lost their plugs within first 6 months

d. Possible complications

i. Displacement of punctal plug

ii. Excessive tearing

iii. Pyogenic granuloma

iv. Canaliculitis

v. Dacryocystitis

vi. Conjunctival and/or corneal abrasion

e. Available Vendor – Beaver-Visitec (**other vendors are available)

i. Call 1-888-905-7770 or visit beaver-visitec.com to set up an account

ii. Parasol punctal occluder (permanent occlusion) – permanent, easily reversible

occlusion for chronic dry eye (comes in 8 pairs/box)

iii. Extend absorbable synthetic implant (mid-term occlusion) – occlusion for up to

3 months – ideal for post-LASIK or other ocular surgery patients (comes in 10

pairs/box)

iv. Collagen implant (short-term occlusion) – occlusion for 7-10 days – ideal for

testing whether punctal occlusion will benefit the patient (comes in 30

pairs/box)

v. Micro Flow (partial occlusion) – ideal for when total occlusion is too much

(comes in 1 pair/box)

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2. Blephex – first medical device available to treat blepharitis

a. New in-practice procedure that moderates the inflammatory etiology of blepharitis

b. A handheld device that consists of a micro-sponge that spins along the eyelid to remove

scurf and debris while exfoliating the eyelid

c. The procedure lasts 6-8 minutes and is usually repeated within 5-6 month intervals

depending on severity of the condition

3. Lipiflow thermal pulsation – first medical device to treat Meibomian gland dysfunction

a. It delivers a combination of heat and pressure to the inner eyelids to safely remove

gland obstructions and stagnant gland content

b. Contraindicated in patients with the following conditions

i. Ocular surgery within prior 3 months

ii. Ocular trauma within prior 3 months

iii. Active ocular infection

iv. Active ocular inflammation, or history of recurrent ocular inflammation

v. Eyelid abnormalities that affect lid function

vi. Ocular surface abnormality that may compromise corneal integrity

c. Caution in patients with the following conditions

i. Moderate to severe allergic, vernal or giant papillary conjunctivitis

ii. Severe eyelid inflammation

iii. Systemic conditions that cause dry eyes (i.e. autoimmune conditions)

iv. Taking medications that cause dryness

v. Esthetic eyelid and eyelash procedures

d. Potential complications include thermal injury to the eyelid or the eye, physically

pressure-induced injury to the eye and corneal infection

Level 4 1. Referral to an ophthalmologist (discretion of OD regarding choice of OMD)

a. Refer if any of the following symptoms occur

i. Visual loss

ii. Moderate or severe pain

iii. Lack of response to the therapy

iv. Corneal infiltration or ulceration

v. Persistent erosion

Punctal cautery – surgical procedure permanently closes punct

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Summary of Dry Eyes Treatment

Mild Dry Eye Treatments

Change environmental factors (and contacts)

Vitamins

Artificial tears

Lid hygiene (scrubs and compresses)

Acute Moderate Dry Eye Treatments

Mild dry eye treatments

Prescription medications (Restasis and Xiidra)

Topical steroids (FML and Lotemax)

Topical antibiotics (Erythromycin ointment, Bacitracin ointment and Azasite)

Oral antibiotics (Doxycycline) for blepharitis or rosacea

Punctal plug

Blephex

Lipiflow

Chronic Moderate Dry Eye Treatments

Mild dry eye treatments

Prescription medications (Restasis and Xiidra)

Oral antibiotics (Doxycycline)

Punctal plug

Blephex

Lipiflow

Severe Dry Eye Treatments Refer to an ophthalmologist

ICD-10 Coding Common Codes with required components3

1. Coding Ophthalmic Visits

a. Comprehensive (92004/92014) – case history (chief complaint, HPI, medical history),

gross visual field, EOM’s, external examination (slit lamp examination), and

ophthalmoscopic examination (i.e. undilated 90D counts)

b. Intermediate (92002/92012) – case history (chief complaint, HPI, medical history),

external ocular and adnexal examination, other diagnostic procedures as indicated

(tonometry, EOM’s, CVF, etc)

2. Coding Evaluation and Management Visits

a. E&M Level 1 – never used by OD’s

b. E&M Level 2 (99202/99212) – i.e. amblyopia, dry eye

c. E&M Level 3 (99203/99213) – i.e. dry eye, corneal abrasion, glaucoma

d. E&M Level 4 (99204/99214) – i.e. acute RD

e. E&M Level 5 – do not use unless you are familiar with the condition enough to be

audited

f. E&M Guidelines (defined by 1997 E&M guidelines)

i. All E/M codes have 3 parts and are defined by how many parts are required

1. Case history

2. Exam components

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3. Medical decision making

ii. New E&M (>3 years) = 3 of 3 parts at that level

iii. Established E&M (<3 years) = 2 of 3 parts at that level

g. Example of Established E&M Level 3

i. Chief complaint: Dry eye follow-up per Dr. Smith

1. 1-3 HPI (Remember FOLDARQ): which eyes have dryness? OU

2. 1 ROS (easiest is to ask for allergies): NKDA, NKMA or (+) penicillin

ii. Exam components (6-8) required (VA, pupils, iris, EOM’s, CVF,

lids/lashes/adnexa, bulbar/palpebral conjunctiva, cornea, anterior chamber,

lens and tonometry)

iii. Medical decision making: Restasis BID. RTC 3 months follow-up

Common ICD-10 Coding for Dry Eye4

Diagnosis – Dry Eye Disease

Keratoconjunctivitis sicca, non-Sjogren’s syndrome, right eye

H16.221

Keratoconjunctivitis sicca, non Sjogren’s syndrome, left eye

H16.222

Keratoconjunctivitis sicca, non-Sjogren’s syndrome, bilateral

H16.223

Conjunctival xerosis, right eye H11.141

Conjunctival xerosis, left eye H11.142

Conjunctival xerosis, bilateral H11.143

Dry eye syndrome of right lacrimal gland H04.121

Dry eye syndrome of left lacrimal gland H04.122

Dry eye syndrome of bilateral lacrimal glands H04.123

Exposure keratoconjunctivitis, right eye H16.211

Exposure keratoconjunctivitis, left eye H16.212

Exposure keratoconjunctivitis, bilateral H16.213

Sicca syndrome (Sjogren) with keratoconjunctivitis

M35.01

Sicca syndrome (Sjogren), unspecified M35.00

Superficial keratitis, unspecified, right eye H16.101

Superficial keratitis, unspecified, left eye H16.102

Superficial keratitis, unspecified, bilateral H16.103

Filamentary keratitis, right eye H16.121

Filamentary keratitis, left eye H16.122

Filamentary keratitis, bilateral H16.123

Punctate keratitis, right eye H16.141

Punctate keratitis, left eye H16.142

Punctate keratitis, bilateral H16.143

Neurotrophic keratoconjunctivitis, right eye H16.231

Neurotrophic keratoconjunctivitis, left eye H16.232

Neurotrophic keratoconjunctivitis, bilateral H16.233

Recurrent erosion of cornea, right eye H18.831

Recurrent erosion of cornea, left eye H18.832

Recurrent erosion f cornea, bilateral H18.833

Diagnosis – Dry Eye Symptoms Normal Osmolarity or Undiagnosed Dry Eye with Symptoms

Visual discomfort, right eye H53.141

Visual discomfort, left eye H53.142

Visual discomfort, bilateral H53.143

Ocular pain, right eye H57.11

Ocular pain, left eye H57.12

Ocular pain, bilateral H57.13

Epiphora, right lacrimal gland H04.201

Epiphora, left lacrimal gland H04.202

Epiphora, bilateral lacrimal gland H04.203

Other visual disturbances H53.8

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Tips for ICD-10 billing a. Dry eye follow-ups are generally E&M level 2/3

b. Underlying systemic conditions should always be the primary diagnosis with the ocular

condition as the secondary diagnosis

c. Try to refrain from using the codes with “Dry Eye Syndrome of Lacrimal Gland” because

insurance companies tend to reject codes with “syndromes” more vs a specific finding

d. Be clear and concise with the chief complaint

*Disclaimer: Please refer to the CPT guidelines and the resources listed below for more information. This section is not intended to replace the CPT guidelines. Resources

1. American Academy of Ophthalmology Corneal/External Disease Panel. Preferred Practice

Pattern Guidelines. Dry Eye Syndrome – Limited Revision. San Francisco, CA: American Academy

of Ophthalmology; 2011. Available at www.aao.org/ppp.

2. Abelson, Mark and Avner Ingerman. “The Dye-Namics of Dry-Eye Diagnosis.” Review of

Ophthalmology. 15. Nov 2005.

www.reviewofophthalmology.com/article/the-dye-namics-of-dry-eye-diagnosis.

3. Borgman, Christopher. “Blue Collar Billing & Coding.”

http://www.sdeyes.org/docs/Blue_Collar_Billing__Coding.pdf. 1 August 2016.

4. “ICD-10 Coding for Dry Eye.” 2015. https://www.tearlab.com/pdfs/940089_Rev_A_-_ICD-

10_Coding_for_Dry_Eye_-_FINAL_-_9-23-15.pdf.

http://www.reviewofophthalmology.com/article/the-dye-namics-of-dry-eye-diagnosis

http://www.sdeyes.org/docs/Blue_Collar_Billing__Coding.pdf

https://www.tearlab.com/pdfs/940089_Rev_A_-_ICD-10_Coding_for_Dry_Eye_-_FINAL_-_9-23-15.pdf

https://www.tearlab.com/pdfs/940089_Rev_A_-_ICD-10_Coding_for_Dry_Eye_-_FINAL_-_9-23-15.pdf

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PHYSICIAN REFERRAL PROTOCOL Purpose: establish uniform procedures for physician referral and documentation of follow-up activity.

I. Determine the Level of Urgency/ Make the Appropriate Referral

A. Severe Urgency: Must be followed up within 24 hours. 1. Identify the doctor patient is referred to. Make a recommendation. 2. Give a copy of the Physician Referral Form to the patient 3. Send patient to hospital Emergency Room if patient’s physician or medical plan cannot be

reached expeditiously.

B. Moderate Urgency: Must be followed up within 3 weeks. 1. Identify the doctor patient is referred to. 2. Give the Physician Referral form to the patient.

C. Elective: Schedule routine follow up with EYEXAM of California as needed. Patient to pursue physician referral at his or her own discretion. No follow up on consult form is needed. 1. Recommend a doctor to refer patient to. 2. Give the Physician Referral form to the patient.

II. Document and Follow-up

A. Severe and Moderate Urgency: 1. Document the referral in the patient’s chart with the appointment time, date, and the name

of the doctor patient is referred to (if known) under the “Plan” section of the original exam which resulted in the referral.

2. File a copy of the Physician Referral form in the patient’s chart. 3. Enter the “date of referral, patient’s name, doctor to whom referred, and follow up due

date” onto the “Physician Referral Follow up Log” (EX-021). 4. File a copy of the Physician Referral in the referral binder under the date in which the follow

up is due. 5. One person should be assigned to review the referral log weekly. 6. If a referral is due on the day assigned to review the referral log, the assigned person should

call the patient on his or her assigned day. Document the “date of the call and the initials of the caller” under the column “Phone Date/Initials” of the referral log.

7. If the patient has gone to the referral and the specialist has sent a report of findings back to our office, the Optometrist should sign the report as proof of having reviewed it. Remove the copy of the Physician Referral Form the binder and file it with the specialist’s report in the patient’s chart. Log the “date” that it was received under “Notes” and write “MD letter received”.

8. If the patient has not seen a specialist by the follow up due date, document the “reason” under “Notes.” Encourage the patient to go and stress the importance of the referral. If the reason is a financial one, remind the patient that urgent care will see the patient without proof of insurance or ability to pay for the visit. Document all conversations with the patient on the pink copy of the referral or directly on the chart.

9. If the patient refuses to comply with the referral, fill out the “Referral Reminder Letter” (EE-119-EE). The Optometrist should sign the letter before sending the white copy to the patient. Remove the copy of the Physician Referral Form the referral log binder and file it in the patient’s chart, along with the yellow copy of the Reminder Letter.

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PHYSICIAN REFERRAL PROTOCOL (cont.)

10. Any incomplete Physician Referral Forms should remain in an “Overdue” section of the binder until at least one phone call and/or letter has been made and documented. At this point, the Optometrist should review all documented attempts to contact the patient, the method by which the patient was contacted, and determine if any further phone calls or letters are necessary based on the severity of the referral. If the Optometrist decides that no further attempts are needed, he/she can sign off the Physician Referral Form, and file it back in the chart.

B. Elective Referrals: File the copy of Physician Referral in the patient’s file.

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STORE & EQUIPMENT MAINTENANCE Each location is designed to project an appealing professional image to our patients as well as to provide patients and associates with a safe environment. It is the Store Manager’s responsibility to ensure that the location is properly maintained. Due to insurance and liability issues, please use Store Maintenance for all service needs. Contacting Store Maintenance:

By Phone (Hotline): 513-765-3500. The ‘Hotline’ is capable of handling all emergency & non-emergency calls 24/7. Please consider holding or bundling multiple, non-emergency Handyman requests prior to calling Store Maintenance Hotline. It is easier for them to put in one work order for a Handyman technician, who will visit your location and resolve all your issues in one trip.

By Email: [email protected].

Off-Hours Emergency Calls: Upon an emergency issue during off hours (i.e, nights, weekends or holidays), contact Store Maintenance Hotline to speak with either an ‘off hour agent’ or to speak directly to a vendor that can handle your specific emergency need. When placing an off-hour service request, be sure to provide the dispatcher with the Brand Name (i.e., LensCrafters), Store Number, Caller Name, Store Phone Number and the nature of the emergency.

Air Conditioning, Heating and Ventilation (HVAC): Luxottica Retail maintains and schedules regional vendors to perform quarterly maintenance visits on every HVAC unit. If there are any unscheduled needed service repair, call Store Maintenance Hotline to request a service call.

Fire Extinguishers, Emergency & Exit Lighting:

Fire Extinguishers: The location and quantity is mandated by the location fire department. Luxottica Retail uses national certified vendors to inspect and tag all fire extinguishers annually, which is required by law. Field or Store Management is required to inspect the extinguishers monthly.

Sprinklers & Fire Alarms: These systems are usually monitored and check by either the mall or landlord. If there are any issues, please contact mall management or the landlord before contacting Store Maintenance Hotline.

Emergency & Exit Lighting: Luxottica Retail requires Field or Store Management to inspect these features monthly. (Upon power failure the locations emergency and exit lighting should operate on battery power and remain lit for 90 minutes).

Flooring: Carpet Replacement: If your carpet is in disrepair, please contact the RVP to be included in with their annual replacement list. (Carpet needs to be at least 5 years or older to be replaced). The location is responsible for vacuuming carpet using a commercial grade upright vacuum every night before leaving. Spills should be cleaned immediately and 6’ to 10’ barrier mats provided by Cintas should be at all exterior entries. Also ensure if getting your carpet cleaned that the carpet cleaning service uses the ‘hot water extraction’ method only, do not use chemicals or rotary/bonnet machines to clean carpet as this will void out the carpet warranty.

STORE & EQUIPMENT MAINTENANCE (cont.)

Floor Care Guidelines: See Janitorial Services and Cleaning & Maintaining the Store checklist.


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Lighting: The Store Manager is responsible for ordering, stocking and replacing lamps and bulbs when necessary. These can be ordered directly by calling Regency Lighting 888-405-6478. Locks & Keys: For lock repairs, replacements and key changes, call Store Maintenance Hotline. The only reasons for changing out any locks are as follows:

Asset Protection has approved or initiated a request to change out all or some of the locks due to theft, termination, etc.

Lock(s) are inoperable

Stores that do not have multi-key lock and have experienced a break in by key. (Some locks such as casework locks can be easily replaced by removing or mounting screws and re-installing a replacement mechanism; thereby, eliminating the need for a locksmith).

Doctor’s Office:

Ophthalmic Equipment: Before requesting costly repair service, first reference the Product Instruction Manual in trying to resolve equipment issues. Replacement manuals can be ordered through Store Maintenance Hotline. If the problem still exists after referencing the Product Instruction Manual, contact Store Maintenance Hotline for further assistance. Make sure to provide information on the manufacturer, model, serial number, description of problem and action taken

Preventative Maintenance: Routine cleaning and calibration is only available by special request and must be approved through your RGM or RDE. Minimize the need by using dust covers. Phoroptors should have the mechanical assemblies cleaned and lubricated once every 3 or 4 years depending on usage.

Housekeeping Supplies: The following are available through Central Purchasing: Regular & Micro-Size Q-Tips, Lens Cleaning Cloths, pure 100% Isopropyl Alcohol, Blower Brush and Equipment Dust Covers.

Jeters Patient Record File Cabinets: Purge all unnecessary, inactive patient files in lieu of requesting an additional cabinet. These file cabinets will only be added after a strict approval process due to the expense.

Daily Tasks: o Cover the exam instruments when not in use. o Check the dust covers for rips. Replace as need via CP. o Blow or brush off dust from all equipment. o Wipe off the outer surfaces using a clean, soft silicone cloth an IPA alcohol as necessary. o Clean the fragile glass or plastic surfaces using IPA alcohol, a lens cleaning cloth and standard Q-tips. Do the same with the eyepiece lenses on all the instruments.

* In addition to calling Store Maintenance Hotline regarding equipment maintenance or equipment replacement, you can also call LUX Emergency Helpline at 866-589-4357 for additional help. EYEXAM of California’s Corporate Office also has a calibration kit that can be ordered by calling Kathy Cook at 949-364-2256 x105. Please allow 3-5 business days for delivery to your location by UPS.

Utilities – Energy (Electric, Water, Gas and Oil):

Billing & Services: If your location has an issue regarding electric services or any other utility then contact Store Maintenance Hotline. Any utility invoices sent erroneously to your location should be faxed to 513-492-3500.

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STORE & EQUIPMENT MAINTENANCE (cont.)

Vacuum Exchange Program: If for any reason your vacuum does not work or replacement parts/supplies are needed, you can call Store Maintenance Hotline or Vacuum Systems International, Inc., 800-997-8227.

Warranty Issues with New/Remodeled Stores (within one year): If your location has been built or remodeled within the last 12 months, then determine if the repairs are covered under the general contractor’s warranty.

Check to see if the defect is an item the contractor installed, or if it’s a defect related to the contractor’s workmanship (and not related to wear & tear). If the answer to both is yes, then refer to your sub-contractor list and call the appropriate contractor to solve the problem. If you don’t have the list or can’t get satisfaction from the contractor, then contact the Project Manager in Store Design for resolution. If it’s none of the above, then call Store Maintenance to issue a work order to an approved service vendor for resolution.

Handyman Program: Handyman program provides for an all trades technician to come out to the location on a set frequency determined by the location. The technician will follow a pre-determined checklist and or completed request work provided by the Store Manager. This program can reduce travel costs to the location and is usually reserved for high profile or high volume stores. Check the Preventative Maintenance Guide for a list of contractors that perform the services.

Janitorial Services: Janitorial services include window, floor and general cleaning (see Preventative Maintenance Guide for a list of contractors that perform this service). Frequency for this service may vary by brand, sales, graphic location and proximity to the outdoors.

To modify any preventative maintenance schedule, the location should do the following;

Change Schedule: contact Store Maintenance Hotline 513-765-3500.

Add Activity or Increase Frequency: Complete a Luxottica Retail Exception Request Form, obtain manager’s approval and fax to 513-492-3500.

Lab Maintenance: It is the Lab Manager and General Manager’s responsibility to ensure that equipment maintenance is completed. All associates are expected to follow the Company’s standards of equipment maintenance.

Daily Maintenance/Calibration: Daily maintenance/calibration must be completed before opening the Lab for production. Associates should complete the specific steps described on the equipment maintenance sticker on each piece of equipment. Upon completion of the maintenance/calibration steps, the associate who performed the task must document their initials on the Maintenance Calendar.

Weekly/Monthly Maintenance: Weekly and monthly maintenance must be performed at the recommended maintenance intervals as outline on the equipment maintenance stickers. Upon completion of the maintenance steps, the associate who performed the maintenance must document their initial on the Maintenance Calendar/Stickers to indicate all maintenance has been completed per the maintenance schedule.

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Section 13: INFORMATION FOR INDEPENDENT CONRACTING PROVIDERS

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USING the PROVIDER MANUAL EYEXAM has established and maintains this Provider Manual that sets forth our procedures that Independent Contracted Providers must follow, as applicable, including but not limited to credentialing and re-credentialing; claim submissions; Quality Assurance; Enrollee Accessibility; Grievances and Appeals; Patient Satisfaction and Language Assistance Program.

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PLAN INFORMATION AND ENROLLMENT

Member Benefits

Providers are expected to be knowledgeable about the Plan’s benefit plan and provide truthful and accurate information to Members and prospective Members about the benefit plan. Provider shall provide prospective and current Members with the Plan’s Evidence of Coverage and other documents required by the Plan. Provider shall enroll as Members those individuals who are not otherwise enrolled in a private or a government funded health care program with an applicable eye examination benefit. Provider shall ensure that each Member is eligible to receive the Covered Services on the date of service prior to providing the Covered Services, in accordance with the Membership Agreement and Plan Provider Manual.

To learn more about our plan, be sure to read the EYEXAM of California Evidence of Coverage.

At time of the initial eye examination, enrollees must pay the Membership Fee of $74.95* to EYEXAM of California.

*Membership Fee Subject to Change. Other Covered Services available at additional cost.

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COMMUNICATIONS Independent Contracted Providers must provide EYEXAM with a valid, working email address so that we may communicate with Provider electronically. Provider consents to the receipt by email of communications, including but not limited to updates to the Provider Manual and amendments to this agreement. Provider will promptly notify EYEXAM of any changes in Provider’s email address. In any such communications both parties will comply with applicable law, including laws regarding member data, protected health information, and other confidential information, as well as the form and format of any such communications.

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RECORD MAINTENANCE

Providers are expected to maintain all member records (both clinical and financial) for 10 years (or longer if state or federal requirements say so). It’s up to you to decide if you want to keep these electronically or in hard copy, as well as how long you want to keep them beyond the 10-year timeframe.

Record confidentiality and HIPAA

You must keep medical records and other protected health information confidential. Your procedures govern the use, collection, verification and removal of member information, as well as how and when to release this information. By law, you need a member’s written consent or permission from the member’s legal guardian before releasing PHI.

If we receive a report of a HIPAA complaint against you, we’ll forward the complaint to you so you can address it within your HIPAA procedures. We’ll also consider this a member complaint. Record availability

Make members’ clinical and all administrative records available to us or other authorities that are reviewing quality of care or investigating a member complaint or appeal. In the event of a member complaint or an audit, you must also provide members’ clinical and financial records upon request. If you leave your practice or leave our network, you need to provide us with a forwarding address so members can get copies of their clinical and administrative records if needed.

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OUT OF OFFICE COVERAGE

While you’re away

Everyone needs a break from time to time. When you’re out of the office for 7 consecutive days or more, you must arrange for coverage by another EYEXAM -credentialed participating network provider. (Shorter absences are up to your discretion.) Be sure to contact us via email to let us know who’ll be filling your shoes before they start seeing our members. We’ll need to associate the provider to your location.

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NAMES & LOGOS

Providers have the right to use EYEXAM’s name solely to make public reference to Provider’s participation status and shall not otherwise use EYEXAM’s name, symbol, trademark or service mark without our prior written approval. Additional information regarding usage guidelines is provided in the Provider Manual. EYEXAM has the right to use Provider’s name in our provider directory and for any other reasonable purposes in connection with administering benefit plans or performing services pursuant to our contracts with clients.

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INSURANCE REQUIREMENTS Independent Contracted Providers must keep the following types and minimum amounts of insurance per location during the terms of your agreement with us. These apply to the contracted eye care professional and all affiliated eye care professionals, except in those states that have limitations on liability. In these states, state law will apply.

Insurance type Provider type Required insurance amount

Professional liability Commercial general liability

MD, DO, OD

$2,000,000 per occurrence $4,000,000 combined

Opticians


MD, DO, OD, Opticians


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FRAUD, WASTE, & ABUSE PREVENTION Independent Contracted Providers must complete Fraud, Waste and Abuse prevention training with all staff each year, unless you’re contracted directly with Medicare. Contact the EYEXAM of California Office or use the Provider Email to let us know you’ve completed your training and for more information, including free training materials.

Our Fraud, Waste & Abuse prevention goals

To effectively pursue the prevention, investigation and prosecution of health care fraud, waste or abuse

To recover overpayments on behalf of our clients

To comply with state and federal regulations and clients’ requirements for preventing fraud

Provider Education & Resources Be sure you’re using our provider resources to stay in the know about all of our policies and guidelines. Here are some of the resources we have available:

Provider Manual: Take time to familiarize yourself with the contents of the manual, which details our policies, processes and other guidelines for participating on the network. Remember your contract requires you to comply with the policies and procedures found in the Provider Manual.

CMS Annual FWA Training: The Centers for Medicare and Medicaid Services (CMS) requires annual compliance training related to fraud, waste and abuse awareness. This requirement affects you as a provider of vision services to our Medicare Advantage members.

Indicators and Examples of Provider Fraud, Waste & Abuse The following is a non-exhaustive list of examples of situations that may constitute provider fraud:

Billing for services not provided

Billing the same service and diagnosis on the same date of service to multiple plans

Up coding or unbundling services to gain greater reimbursement

Providing something to the member that was not necessary (treatment, supplies, medicines, procedures, etc.,) for the purpose of billing the benefits company

Making an intentional misrepresentation on your claim about the nature of services or charges, the sequence dates of service, filing for an altered or falsified diagnosis to obtain coverage, the provider of services (i.e. filing a claim indicating a provider that is in the member’s network, but it is not the provider that supplied the service), the recipient of services (i.e. filing a claim under an eligible member when the service was received by an ineligible member)

Stating medical necessity for routine services

Diagnosis or treatment out of scope of the provider’s practice Best Practices to Prevent Fraud, Waste & Abuse

DO maintain complete and accurate records. Remember you have a responsibility to maintain complete and accurate records, either in hard copy or electronically, for a period of 10 years (or longer if state or federal requirements say so) and to cooperate during our audits to furnish those records. If we don’t have sufficient documentation to validate the services and/or materials filed on your claim(s), we will collect the claim reimbursement to correct this overpayment either by requesting a refund or by withholding future payments where permitted by law.

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DO ensure that all information submitted on authorizations and claims is accurate. Remember you are responsible – we will hold you responsible for claims submitted by you, your employees and agents of your practice. If we identify any misleading or false information included on your claim(s), we may consider that a false claim resulting in recoupment and disciplinary action up to and including termination from the network.

DO speak up if you notice suspicious activity. If you discover that your office currently or previously committed any improper billing practices, we encourage you to proactively communicate this to us and we will take this into consideration during our review.

Consequences of Identified Fraud, Waste or Abuse

Identified fraud, waste or abuse may result in some or all of following:

Provider education and warning

Monitoring of the provider’s submitted claims activity and/or implementation of a Corrective Action Plan

Comprehensive provider audit and/or quality review of the provider’s claim activity

Withholding of the provider’s claim payments or demand for restitution for recovery of overpayments

Termination of the provider from the network

Reporting of suspected fraudulent activity to comply with state and federal regulations and/or clients’ requirements

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GETTING PAID

As you transition from employment to a sublease arrangement, you will also transition from receiving a paycheck to receiving a reimbursement payment for services rendered as a provider for EYEXAM of CA. To simplify this transition, EYEXAM will continue to process all member transactions for professional services (except medical services not included under the EECA Membership Plan) through the existing point of sale (POS) system and will collect member/patient premiums, copays, and out-of-pocket expenses on your behalf. EYEXAM will reimburse you every two weeks for services rendered, which will provide predictability and simplicity for you as you transition to a contracted provider. These payments will appear via direct deposit into the bank account of your choosing. EYEXAM members will continue to be charged for covered services in accordance with the EECA Membership Plan and you will be reimbursed as described in the Vision Care Provider Agreement. Other enrollees who access care through an EyeMed Managed Vision Care plan or other discount plans will be charged for services in accordance with their benefit plan, including applicable copayments and benefits. When rendering services to these members, you will be reimbursed as described in the Vision Care Provider Agreement. While EYEXAM will provide the infrastructure for processing Managed Vision Care transactions for vision care programs with which it has a relationship and for processing of the EECA Plan Memberships, it will have no role in patient transactions which are billed to medical plans. You will be responsible for processing transactions for medical services; however, EYEXAM will provide you with an electronic health record (EHR) system and training to help simplify that process as well. EYEXAM is dedicated to ensuring that your payments are both accurate and timely to allow you to focus on your practice and your patients.

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NON-COVERED SERVICES

Provider will not charge a Member higher fees than you regularly charge private pay patients (i.e., non-members) for any professional services, materials, or other goods that are not covered services. Provider will comply with any requirements set forth in the Provider Manual regarding non-covered services. Note: A Description of all Covered Services can be located in the EYEXAM of California Evidence of Coverage

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