PatientInformationFormPatient’sLegalName:________________________________________DOB:_____________Sex:M/F

Address:___________________________________________City:_________________State:_______Zip:_________

HomePh:_________________________CellPh:_____________________E-mail:_____________________________

Guardian#1orSpouse’sName:_____________________________CellPh:_____________________

Guardian#2:____________________________________________CellPh:_____________________

Occupation/Grade:__________________________Employer/School:________________________________________

IherbygivepermissionforSEG&Affiliatestoleavedetailedmessagesonmyvoicemail/answeringmachine.

IherbygivepermissionforSEG&Affiliatestosendmeemails

Inordertoconnectyouraccountwithafamilymember,pleaselisttheirnamesandages:(parents,children,siblings)

Name:_____________________________Age:_______Name:________________________________Age:_______

Name:_____________________________Age:_______Name:________________________________Age:_______

Howdidyoufindoutaboutus?_______________________________________________________________________

Referredby:_______________________________________________________________________________________

ACKNOWLEDGEMENTOFNOTICEOFPRIVACYPRACTICES

¨ IwasgiventoopportunitytoreadSpecialtyEyecareGroup’sNoticeofPrivacyPractices.IhaveeitherreadorIdeclinedtoread.IwishtocontinuemycarewithSpecialtyEyecareGroupunderthetermsofSpecialtyEyecareGroup’sprivacypolicies.

¨ Iamover18andallowmyinformationbesharedwithmyfamilyforpurposesofhelpingmedecideuponmycareand/ortoensurethatbillingiscompletedproperly.

Signature____________________________________________________Date____________________________________

FINANCIALAGREEMENT

InsigningthisstatementIagreetobefinanciallyresponsibleforallcharges.Iunderstandthatmyinsuranceisnotasubstituteforpaymentanditismyresponsibilitytopay,inadvance,thedeductible,theco-payandanyotherbalancenotpaidbymyinsurancecompany. I alsounderstand that verificationofmybenefits is not a guaranteeofpayment.Most insurancepolicies payonly aportionofthetotalfees.Ifyouhavequestionsaboutyourcoverage,pleasecontactyourinsurancecompany.Allaccountsover60dayswillreceiveaninterestchargeof18%.

IunderstandthatIamresponsibleforchargesforservicesandproductsthatarenotcoveredbymyinsuranceplan.

Signature____________________________________________________Date____________________________________

HEALTHInformationFormPtName D.O.B. LastEyeExamOn:____________________Doctor’sName:_____________________________Phone#______________________

MedicalDoctor:______________________Clinic:_____________________________________Phone#______________________

OtherDoctor:________________________Clinic:_____________________________________Phone#_____________________

Medications(PrescribedandOTC)_______________________________________________________________________________

Allergies(Medications):________________________________________________________________________________________

Allergies(Seasonal/Other):_____________________________________________________________________________________

DevelopmentalDelays?_______________________________________________________________________________________

Therapy/Tutoring?_____________________________________Provider:_____________________________________________

Therapy/Tutoring?_____________________________________Provider:_____________________________________________

Previousheadtrauma/injury?Ifyes,when?_____________WhatOccurred?:__________________________________________

Sports/Hobbies/Activities:_____________________________________________________________________________________

Whatactivitiesrequireprotectiveeyewear?______________________________________________________________________

SOCIALHISTORY

Drinking:YES/NOAmount(Weekly):____________ RecreationalDrugUse:YES/NOType/Amount_______________

SmokingStatus:YES/NOAmount(Weekly):____________Current/Former/Heavy/Light/Never

PersonalEyeHealthHistory

Y N Y N Y N

Fulltimeglasseswear Whiteappearanceinpupil Frequentlossofplace

Glasseswearfordistanceonly Squinting/eyerubbing/blinking Omits/Inserts/re-reads’lettersorwords

Glasseswearfornearonly Headaches Poorreadingcomprehension

Softcontactlenswear Red/Itchyeyes Confusessimilarlookingwords

Rigidcontactlenswear Blurry/doublevision Reversalsafter1stgrade

Strabismussurgery CrossedorLazyeye Smartineverythingbutschool

*Ifyes,Righteye Headtilting/closingeye Fatigue/frustrationwithhomework

*Ifyes,Lefteye Difficultycopyingfromboard Fatigue/frustrationwithreading

Previouseyeinjuries Poorhandwriting,misalignsnumbers Difficultieswithreading

*Ifyes,Righteye Inconsistent/poorsportsperformance Difficultieswithspelling

*Ifyes,Lefteye Holdsbooksclosely Difficultieswithmath

Anylossofvision Avoidanceofnearwork Isyourchildmeetingtheirpotentials

PersonalHealthHistory

Constitutional Y N Cardiovascular/Respiratory Y N Musculo/Integ/Endocrine Y N

DevelopmentalDisabilities Hypertension Arthritis:Osteo/Rheumatoid

Cancer Stroke/CVA Fibromyalgia

FatigueSyndrome HeartDisease MuscularDystrophy

Other? VascularDisease AnkylosingSpondylitis

ENT CongestiveHeartFailure Osteoporosis

HearingLoss Other Gout

Sinusitis CigaretteSmoker Eczema

DryMouth Asthma Rosacea

Laryngitis Bronchitis/Emphysema Psoriasis

Other ChronicObstruction HerpesSimplex(coldsores)

Neurological SleepApnea HerpesZoster(shingles)

MultipleSclerosis Other Type1DiabetesMellitus

Epilepsy Gastrointestinal/Genitourinary Type2DiabetesMellitus

CerebralPalsy Crohn’sDisease ThyroidDysfunction

Tumor Colitis HormonalDysfunction

Stroke Ulcer Other

Migraine AcidReflux Hemotological/Lymphatic/Immune

Other CeliacDisease Anemia

Psychological KidneyDisease Large-volumeBloodLoss

Depression ProstateDisease/Cancer Ulcer

AttentionDeficit STD Hypercholesteremia

AnxietyDisorder BenignProstateHypertrophy Lupus

BipolarDisorder Pregnant/Nursing Sjogren’sSyndrome

Other Other Other

FamilyMedicalandOcularHistory

ConditionY N Mother Father Sister Brother Mat.G-

motherMat.G-father

Pat.G-mother

Pat.G-father

Cancer:

DiabetesMellitus

DiabetesMellitusType1

DiabetesMellitusType2

Hypertension

Hyperthyroidism

Hypothyroidism

ThyroidDisorder

Cataract

MacularDegeneration

Glaucoma

Other:

PATIENT FINANCIAL AGREEMENT Thank you for choosing Specialty Eyecare Group. Our mission is to enrich lives so that others can succeed to their greatest potential. We strive to do this by creating uncompromised service and happiness. In order to make sure that we are all on the same page regarding our financial relationship, we ask that you read and understand the following. The funds necessary for your eye care treatment are ultimately your responsibility. FOR THE PATIENTS WITH CLAIMS THAT WILL BE BILLED TO THEIR MEDICAL OR VISION INSURANCE PLAN: Your insurance is a contract between you and your insurance company and not between Specialty Eyecare Group and the insurance company. Acceptance of insurance assignment by our office does not absolve you of your responsibility for the charges for the treatment we provide to you. In most cases, we will attempt to provide you an estimate of the charges for the services that we provide in order to serve as a guideline until final insurance payment is received and your financial account has been reconciled. We can make no guarantees of the insurance payment. If your insurance does not pay for a procedure or informs us that your copayment or deductible is more than what we had initially charged at the time of your visit, you are responsible for payment in full. If there are any discrepancies please contact your insurance company and/or your employer’s benefit department. IF YOU HAVE A DEDUCTIBLE that has not been met, we will collect for the service that we perform on the day of the visit. Your insurance will still be billed so that the service will count towards your deductible. Accounts that are outstanding for 60 days or more may be subject to a 18% interest charge. In the event that your balance is sent to the collection agency, you are responsible for full payment of your account to the collection agency. You will also be responsible for any interest, late charges or fees related to collecting of your balance. Specialty Eyecare Group charges $75 for returned checks. A fee of $75 is charged for patients who miss or cancel an appointment without a 24 hour notice. We are in a service industry and our appointment slots are how we serve patients. If you cancel your appointment it means we don’t get to serve someone else, unless we have enough notice. I understand and agree to take full responsibility as outlined in this financial agreement for the patient listed below. Any termination of this agreement may only be done in writing and will not apply to any action in process. _______________________ _________________________ _______ Patient Name (please print) Patient/Guardian Signature Date

Modified 7/1/2017

Contact Lens Wear Notice: At Specialty Eyecare Group we strive to provide you with the clearest vision and safest contact lenses for your eyes. Washington State law requires that you receive a contact lens evaluation to minimize potentially serious complications related to contact lens wear. Services rendered for contact lens evaluation are not included in an eye health evaluation and vision assessment. The contact lens service fees in this office reflect the expertise and time of the employees and physicians overseeing your care. These fees are outlined on the right. Please Sign and Date One of the Following:

I CONSENT to have a contact lens evaluation. I have read and understand the office policies and agree to the contact lens service fee schedule. Print Name (Parent or Guardian) Patient Name

Signature (Parent or Guardian) Date I DECLINE to have a contact lens evaluation at this time but acknowledge the office policies and contact lens service fee schedule. I understand that I will not receive a contact lens prescription at this time.

Print Name (Parent or Guardian) Patient Name

Signature (Parent or Guardian) Date

Contact Lens Service Fees:

Fees include the assessment of current lenses for fit, power, and health.*

ü Up to 4 follow-up appointments pertaining to the contact lens evaluation are included within the first 90 days.

ü Additional follow-up appointments pertaining to the contact lens evaluation are $100 for the initial 90 days.

ü In the event that a contact lens evaluation is not successful the fees for services rendered are not refundable.

If you wear standard soft lenses** the fee is one of the following:

1. Spherical: $175.00 2. Toric (for Astigmatism): $225.00 3. Multi-Focal or Spherical Mono-vision: $250.00

If you wear RGP/Custom Lenses** the fee is one of the following:

Initial Fit or Refit (Rx, Style or Design Change):

1. RGP or Custom Soft Spherical: $250.00

2. RGP or Custom Soft Toric or Multi-Focal: $400.00 If you have specialty contact lens needs due to Keratoconus, other medical issues or complex contact lens fitting issues, there is a separate fee schedule. Please notify us if you know that you wear specialty contact lenses. * If you are a new contact lens wearer there will be a $25.00 training fee. ** If your spherical prescription is +/- 8.00 or your cylindrical prescription is over –2.50 your contact lens will be considered a Custom Lens.

The cost of the contact lens supply is not included in the Service Fees.

Notice of Privacy Practices

Specialty Eyecare Group 11830 NE 128th St., Ste. 1 Kirkland, WA 98034

1911 4th Ave, Seattle, WA 98101 425.821.8900

Dr. David Kading, Privacy Official 06-20-2017

We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices and abide by the policies in it. This notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not. Examples of how we might use or disclose health information for treatment purposes might include:

Setting up or changing appointments including leaving messages with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails, text or email; calling your name out in a reception room environment; prescribing glasses, contact lenses, or medications as well as relaying this information to suppliers by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills; notifying you that your ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails, text or emails; referring you to another doctor for care not provided by this office; obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health; sending you postcards or letters or leaving messages with those at your home who may answer the phone or on answering machines, voice mails, text or emails reminding you it is time for continued care; at your request, we can provide you with a copy of your medical records via email transmission or through our secured patient portal.

Examples of how we might use or disclose health information for payment purposes might include:

Asking you about your vision or medical insurance plans or other sources of payment; preparing and sending bills to your insurance provider or to you; providing any information required by third party payors in order to ensure payment for services rendered to you; sending notices of payment due on your account to the person designated as responsible party

IN COMPLIANCE WITH THE FEDERAL REGULATIONS OF HIPAA’S PRIVACY RULE, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO IT. PLEASE REVIEW IT CAREFULLY.

or head of household on your account with fee explanations that could include procedures performed and for what diagnosis: collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney’s office. At the patient’s request we may not disclose to a health plan or health care operation information related to care that you have paid for out of pocket. This only applies to those encounters related to the care you want restricted and only to the extent a disclosure is not otherwise required by law. Examples of how we might use or disclose health information for business operations might include:

Financial or billing audits; internal quality assurance programs; participation in managed care plans; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; Medicare or Medicaid audits; providing information regarding your vision status to the Department of Public Safety, a school nurse, or agency qualifying for disability status

USES AND DISCLOSURES FOR OTHER REASONS NOT NEEDING PERMISSION In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could.

§ When a state or federal law mandates that certain health information be reported for a specific purpose

§ For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices

§ Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime

§ Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative hearings

§ Disclosures to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial

§ Disclosures to organizations that handle organ or tissue donations § Uses or disclosures for health related research § Uses or disclosures to prevent a serious threat to health or safety of an individual or

individuals § Uses or disclosures to aid military purposes or lawful national intelligence activities § Disclosures of de-identified information § Disclosures related to a workman’s compensation claim § Disclosures of a “limited data set” for research, public health, or health care operations § Incidental disclosures that are an unavoidable by-product of permitted uses and disclosures § Disclosure of information needed in completing form from a school related vision screening,

information to the Department of Public Safety, information related to certification for occupational or recreational licenses such as pilots license.

§ Disclosures to business associates who perform health care operations for Specialty Eyecare Group and who commit to respect the privacy of your information. We also require any business associate to require any sub-contractor to comply with our privacy policies.

§ Unless you object, disclosure of relevant information to family members or friends who are helping you with your care or by their allowed presence cause us to assume you approve their exposure to relevant information about your health

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES It is the policy of Specialty Eyecare Group for our staff to take phone calls from individuals on a patients behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Specialty Eyecare Group staff will also assist individuals on a patient’s behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s vision or health status may be disclosed without proper patient consent. Specialty Eyecare Group staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that individual. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information or uses and disclosures involving marketing unless you sign a written Authorization for Release of Identifying Health Information. The content of this authorization is determined by applicable state and federal law. The request for signing an authorization may be initiated by Specialty Eyecare Group or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may decline to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to the Privacy Officer named at the beginning of this Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your personal health information. You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to Privacy Officer named at the beginning of this Notice. We do not have to agree to your request, but if we agree, must honor the restrictions you ask for. You may ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home or using some special email address. We may accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred in accommodating your request. Requests for special communication requests must be made to the Privacy Officer named at the beginning of this Notice. You may ask to review or get copies of your health information. For the most part we are happy to provide you with the opportunity to either review or obtain a copy of your medical information but rare situations may restrict release of the information. In such cases we will provide you such denial

in writing. Another licensed health care practitioner chosen by Specialty Eyecare Group may review your request and your denial. In such cases we will abide by the outcome of that review. All requests for review or copy of medical information must be made in writing to the Privacy Officer named at the beginning of this Notice. While we usually respond to these requests in just a day or so, by law we have fifteen (15) days to respond to your request. We may request an additional thirty (30) day extension in certain situations. Health care information you request copies of may be delivered to you in electronic format. The e-formats Specialty Eyecare Group has approved include secure email, an authorized Electronic Health Information system and media supplied by Specialty Eyecare Group. You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to the Privacy Officer named at the beginning of this Notice. We will then send the corrected information to you or any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include. You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years (or a shorter period if you wish). Routine disclosures would include those used your treatment, payment, and business operations of Specialty Eyecare Group. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $25.00 per list. We will usually respond to your written request (made to the Privacy Officer named at the beginning of this Notice) within thirty (30) days but we are allowed one thirty (30) day extension if we need the time to complete your request. You may obtain additional copies of this Notice of Privacy Practices from our business office or online at our website address shown at the beginning of this Notice. BREACH NOTIFICATION POLICY

In the event of a reportable breach of patient information, Specialty Eyecare Group agrees to abide by the breach notification requirements as established by the HIPAA Breach Notification Rule. If a breach occurs, Specialty Eyecare Group will take all necessary steps to remain in compliance with this rule including as applicable notification of individuals, Business Associates, the Secretary of Health and Human Services and prominent media outlets.

WHISLEBLOWER PROTECTION RULE

Specialty Eyecare Group will take no action against any individual who provides information to the Office of Civil Rights, Office of the Inspector General or individual state Attorney General’s Office regarding concerns related to the privacy and security procedures or actions at Specialty Eyecare Group.

CHANGING OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to substantially change the Notice. We reserve the right to change this Notice at any time. If we change this Notice, the new privacy practices will apply to your existing health information as well as any additional information generated in the future. If we change this Notice, we will post a new Notice in our office and on our website. COMPLAINTS If you think that anyone at Specialty Eyecare Group has not respected the privacy of your health information, you are free to complain to the Privacy Officer named at the beginning of this Notice. We are more than happy to try to resolve any concern you may have in writing. You may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights or the state Attorney General’s Office. We will not retaliate against you if you make such a complaint. QUESTIONS If you have any questions or concerns we encourage you to contact the Privacy Officer at the number on this notice.