"I request that payment of benefits be made to me or the doctor for any services provided. I also authorize any holder of medical information about me to release to the carrier and its agents any information needed to determine these benefits or the benefits payable for related services."
"I understand that any services not covered by insurance and co-pays are due at time of service."
"I also acknowledge that I will have an opportunity to receive a copy of the Privacy Practices and Policies of this practice."
Personal & Family Medical History
Please note any personal and/or family medical history (parents, grandparents, siblings; living or deceased) for the following conditions:
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Your Medical History
Have you experienced?
POLICY FOR MEDICAL VISITS
Medical visits include examination and treatment for infections, injuries, eye pain, diabetic eye care and eye disturbances other than comprehensive eye health and vision exams, eyeglasses, and contact lenses.
Medical visits and medical insurance coverage are separate from optical coverage (glasses and/or contacts). Medical visits are billed to outpatient medical insurance, the same as visits to a family doctor. You may have a separate insurance plan that contributes towards glasses and/or contacts.
For example: If you see the doctor for a medical visit, our staff will gladly file a claim with your insurance carrier. if we are considered out-of-network with your plan, payment will be required at the time of service and documenation can be provided for reimbursement.
THE CHARGES ARE ULTIMATELY YOUR RESPONSIBILITY. Please help us get your benefits by providing current and accurate insurance information. Unpaid charges are subject to a 18% finance charge.
I have read and agree to the terms stated above.
I authorize the release of information including the diagnosis, records, examination rendered to me and financial information. This information may be released to:
This Release of Information will remain in effect until terminated by me in writing.
Effective date of notice: April 14, 2003Updated August 1, 2013
HIPAA Notice of Privacy Practices
Chesterfield Optometric Center 9440 Ironbridge Road Chesterfield, VA 23832Phone: (804) 748-4877
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW VOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. 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 reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care.
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we may mail an appointment reminder on a post card, and/or send an email to a provided address, text message to a mobile phone, leave a reminder message on your home answering machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice, or “attention acting HIPAA Privacy Officer.”
You have the right to be notified of unauthorized access of your protected health information.
We will not sell or otherwise transfer your health information for marketing purposes without your specific authorization of that transaction. We will use your information for our own marketing purposes such as newsletters, promotions, product announcements, and changes in the practice that affect your care. We will get your authorization first for written or electronic communications in which we are receiving financial remuneration from outside sources.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice, or send correspondences to “Acting HIPAA Privacy Officer.”