( ) Eye Optique ( ) Dr. Julia Bond Health / Vision Insurance Claim Form: YOUR EYECARE SERVICES WERE PROVIDED BY: Street DOB: ID#: Your Phone#: PROCEDURE LOt . SOURCE: CURRENT PROCEDURAL TERMINOLOGY - 4TH EDITION EXAMINATION SERVICES New Established Fee Intermediate Ophthalmic 92002 92012 Comprehensive Ophthalmic 92004 92014 Office Visit 10 99201 99211 Office Visit 20 99202 99212 Office Visit 30 99203 99213 Office Visit 45 99204 99214 Office Visit 60 99205 99215 Refraction 92015 SPECIAL PROCEDURES Biomicroscopic photography 92285 Chalazion, single 67800 Chalazion, multiple 67801 Color vision extended 92283 Dark Adaptometry extended 92284 Electro-Oculography EOG 93370 ElectroRetinography ERG 93375 Epilation for trichiasis 67820 Foreign body corneal 65222 Foreign body conjunctival 65210 Foreign body eyelid 67938 Gonioscopy 92020 Lacrimal Irrigation 68840 Ophthalmoscopy BIONOLK 92225 Punctal dilation 68800 Punctal Implant (per duct) 68761 Refraction 92015 Retinal Photography 92250 Sensorimotor Evaluation 92060 Trichiasis - electrolysis 67825 Tonometry, serial 92100 Ultrasound - A (with IOL calc ) 76519 Contact B Scan 76512 Visual Fields - limited 92081 Visual Fields - quantitative 92082 Visual Fields - static threshold 92083 Visually Evoked Potential 92280 Unlisted special procedures 92499 Other codes Other codes LOW VISION AND VISUAL THERAPY SERVICES Amblyopia Therapy - BV 98681 Binocular Vision Therapy non-strabismus - BV 98683 Design/prescribe Spectacle/single element aid - LV 92354 Design/prescribe Compound element aid - LV 92355 Developmental testing - higher functions - DV 95881 Developmental therapy - DV 98684 Neuromuscular Re-education 97112 Ocular Motility Studies 98316 Oculomotor Therapy 98685 Orthoptics - Visual Therapy - per session - BV 92065 Strabismus therapy - rehabilitation - BV 98682 Unlisted neurological/neuromuscular diagnostic 95999 H52.02-Hypermetropia left eye H52.03 Hypermetropia bilateral H52.10-Myopia unspecified eye H52.11-Myopia right eye H52.12-Myopia left eye H52.13-Myopia bilateral I-152.201-Unspecified astigmatism right eye H52.202-Unspecified astigmatism left eye H52.203-Unspecified astigmatism bilateral H52.211-Irregular astigmatism right eye H52.212-Irregular astigmatism left eye H52.213-Irregular astigmatism bilateral H52.221-Regular astigmatism right eye H52.222-Regular astigmatism left eye H52.223-Regular astigmatism bilateral H52.229-Regular astigmatism unspecified eye H52.31-Anisometropia H52.32-Anisekonia H52.4-Presbyopia ASSIGNMENT AND RELEASE: I HEREBY AUTHORIZE THE PHYSICIAN TO RELEASE ANY INFORMATION REQUIRED TO PROCESS THIS CLAIM. I ALSO AUTHORIZE MY INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN, AND I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES. SIGNED Date NEXT APPOINTMENT Eye Optique 10800 Alpharetta Highway Suite 220 Roswell, Georgia 30076 770-642-7720 ( ) Dr. Julia Bond NPI# 1861425506 ( ) Edward Kleinman NPI# 158084961 ( ) Eye Optique NPI# 1912108119 ( ) Eye Optique Tax ID# 58-1672353 DIAGNOSIS AND/OR CONCURRENT CONDITIONS: ICD-9-CM Abnormal Pupil Reflexes 379.40 GLC, Anatom Narrow Angles 365.02 Accomm. Dyst 367.50 GLC, Narrow Intermittant 365.21 Amaurosis Fugax 362.34 GLC, Narrow-Acute 365.22 Amblyopia, Anisometropic 368.03 Headache 784.00 Amblyopia. Strabismic 368.01 Histoplasmosis - POHS 115.02 Aphakia 379.31 H. Simplex, Ophthalmic 054.40 Pseudophakia V43.1 H. Zoster, Ophthalmic 053.20 Arthritis multiple sites 716.99 Hordeolum 373.10 Binocular Dysf 368.30 Hyperemia, Ocular 372.71 Blepharitis 373.00 Hyperphoria 378.43 Blepharochalasis 374.34 Hyphema 921.30 Blepharospasm 333.81 fridocyclitis 364.00 Burn, eye(s) (unspec.) 940.90 Iris, Synechiae (unspec) 364.70 Cataract, late onset PSC 366.14 Keratitis, SPK 370.21 Cataract, late onset Cortical 366.15 Keratoconjunctivitis 370.33 Cataract, late onset NS 366.16 Keratoconus 371.60 Cataract, Incipient 366.12 Macular Degeneration DRY 362.51 Cataract, mature 366.17 Macular Degeneration WET 362.52 Cataract: "After" 366.53 Meibomianitis 373.12 Chalazion 373.20 Metamorphopsia 368.14 Chorioretinal Scars 363.30 Migraine, unspecified 346.90 Chorioretinitis 363.20 Nevus, Choroidal 224.60 Color Vision Defect 368.50 Night Blindness (unspec) 368.60 Conjunctivitis, Mucopurulent 372.03 Normal V65.50 Conjunctivitis, Follicular 372.12 Nystagmus, irreg. EM 379.50 Conjunctivitis, Allergic 372.14 Ocular motor dsyf 378.90 Conjunctivitis, Viral 077.90 Optic Atrophy 377.11 Conjunctival Hemmorrhage 372.72 Optic Neuropathy, Ischemis 377.41 Convergence Excess 378.84 Palsy, NIII 378.51 Convergence Insuff 378.83 Palsy, NIV 378.53 Corneal, Abrasion 918.10 Palsy, NVI 378.54 Corneal, Erosion (RCE) 371.42 Papifledema 377.01 Corneal, Neovascular 370.61 Photophobia 368.13 Corneal, Endo Pigment 371.13 Photopsia 368.15 Corneal, Opacity (idiopathic) 371.21 Pigmentary dispersion 364.53 Corneal Ulcer (unspecified) 370.00 Pinguecula 372.51 Development, disorder 315.50 Pseudo-Tumor, Orbital 379.11 Development, delay in 315.80 Pterygium 372.40 Diabetes, eye manifestations 250.50 Ptosis 374.30 Diplopia 368.20 Pursuit EM deficiency 379.58 Drusen, Disc 377.21 Refractive change, transient 367.81 Drusen, Retinal 362.57 Retinal detach 361.00 Dry Eyes 375.15 Retinopathy (BDR) 362.01 Ecchymosis 921.00 Retinopathy, Hypertensive 362.11 Ectropion 374.10 Retinopathy, CRAO 362.32 Entropion 374.00 Retinopathy, CRVO 362.35 Epiphora 375.20 Retinopathy, BRAO 362.31 Episcleritis, Nodular 379.02 Retinopathy, BRVO 362.36 Episcleritis, Spec 379.09 Retinopathy, Vein Engorgement....362.37 Esophoria 378.41 Retinopathy, Hemorrhage 362.81 Exophoria 378.42 Saccadic EM deficiency 379.57 Exophthalmos 376.30 Scleritis 379.02 Eye, contusion 921.90 Strabismus, accommodative 378.35 Eye, pain in or around 379.91 Strabismus, convergent 378.00 Eye, redness or discharge 379.93 Strabismus, divergent 378.10 Eyelid, inflam. (unspec) 373.90 Strabismus, vertical 378.31 Eyelid, neoplasm (benign) 216.10 Toxoplasmosis - ocular 130.20 Foreign body, corneal 930.00 Thyroid, disorder 242.00 Foreign body, eyelid 374.86 Trichiasis 374.05 GLC. Open Angle - Suspect 365.01 Vision Loss Transient (TVO) 368.12 GLC, Suspect - Ocular HTN 365.04 Visual Field Defect 368.40 GLC, Open Angle - Chronic 365.11 Vitreous detachment - PVD 379.21 GLC, Open Angle - Low Ten 365.12 Vitreous floaters 379.24 GLC, Pigmentary 365.13 Xanthelasma 374.51 MATERIALS Fees Frames V2020 SV Lenses V210_ RT/LT BF Lenses V220_ RT/LT TF Lenses V230 RT/LT Aphakic BF V2430 RT/LT Photochr V2744 RT/LT UV400 V2755 RT/LT Tint V2740 RT/LT Prism V2715 RT/LT Slab-Off V2710 RT/LT Oversized V2780 RT/LT EW CL Aph V2523 RT/LT CL COS V25_ RT/LT Total Fees: Accept Assignment: Adjustments/ Insurance Discounts: S () YES ( ) NO Amount Paid Today: ( ) CoPayments Balance Due from Insurance Co: Date: Provider / Anthnrized Sionstore Patient's Name: Date: Last First Address: City/State Zip Insurance Company SS#: Email Address: Note: Retractive diagnosis and eyeglasses are usually covered by eyeglass plans-- not major medical. REFRACTIVE DIAGNOSIS Myopia 367.1 Hyperopia 367.0 Presbyopia 367.4 Astigmatism 367.20 Additional Diagnosis