MEDICARE INFORMATION AND CONSENT

ASSIGNMENT OF SERVICES:
We accept assignment for MEDICARE service. Accepting assignment means:

1. Fees are reduced according to MEDICARE guidelines.
2. MEDICARE PAYS 80% of covered services.
3. YOU PAY 20% of covered services.
4. YOU PAY the annual deductible.
5. YOU PAY for any non-covered services.

NON-COVERED SERVICES:

Services not covered by MEDICARE:

1. Routine exam - Medicare designates as "routine" diagnosis such as normal exam, myopia, hypermetropia, presbyopia, astigmatism, screen for disease.
2. Refraction- the determination of your new eyeglass prescription.
3. Photography-except for retina and optic nerve photography.
4. Contact lens services.

MEDICALLY UNNECESSARY SERVICES:

Sometimes Medicare will consider an examination or services as "not reasonable and necessary." If a service is denied by Medicare, you cannot be charged unless:

1. Prior to performing the service you were notified and agreed to pay for the Services.'
2. We could not reasonably have been expected to know that MEDICARE would not pay.

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Hart Eye Care, P.C. For any services furnished by them. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable or benefits payable for related services.