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Supply BOTH your Vision and Medical/Health insurances below for our files

Payment, Medical Release Authorization, and Insurance Assignment

All fees paid for professional services are non-refundable and must be paid at the time of service.  All insurances must be pre-approved prior to your examination. Sensitive ID information is provided by the patient/guardian for the sole purpose of medical record keeping, insurance verification and claims processing. Patient authorizes that payment of vision and medical insurance be made to Ahren Castro OD PLLC d/b/a Prime Eye Center for services provided.  Patient is financially responsible for co-pays and deductibles incurred by the insurance.  If the patient is not eligible for insurance benefits or are eligible for less than full coverage, the patient agrees to be financially responsible for any unpaid balance.  If it is discovered that the patient has insurance after services are rendered, it is the responsibility of the patient to file his/her own claim for reimbursement.  Our office will not back-file claims, post authorize, or refund fees.  The patient also acknowledges that certain examinations and examination findings may not fall within the realm of a routine eye exam, and may deem to be medically necessary to file under your medical/health insurance or will need to be referred to another office.  The patient also authorizes the release of any medical or other information to process insurance claims.

If you are a current contact lens wearer or are interested in wearing contact lenses, you will need a contact lens evaluation.

The goal of a contact lens evaluation (fit) is to find the most appropriate contact lens for each patient's optimal vision and comfort. Before a person can be fit with contact lenses, a complete medical and refractive eye examination is necessary. This exam is critical to assure the good health of your eyes and to rule out the possibility of any unsuspected, underlying condition that may prevent contact lens use.

The contact lens evaluation (fit) fee is not included in the fee for your eye exam and may not fully covered by your insurance.

The fee for your contact lens evaluation includes the initial visit and visits directly related to contact lens wear within a 90 DAY PERIOD. There may also be an additional fee for a first time contact lens wearers requiring a training session on insertion, removal, and care. All fees are due in full at the time of the fitting evaluation and are non-refundable services rendered.

The doctor will examine the health of your eyes annually to ensure that you are a proper candidate for contact lenses.

You are responsible for scheduling and attending your follow up visit to finalize your prescription. Without a finalized prescription, you will not be able to order contacts.

NOTICE OF PRIVACY PRACTICES

Ahren Castro OD PLLC d/b/a Prime Eye Center
10750 Westview Dr.
Houston, TX  77043
713-465-0200
Ahren Castro, Privacy Official

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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.

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  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. We routinely use and disclose your medical information within the office daily. 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 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; referring you to another doctor or clinic for eye care services; or obtaining copies of your health information from another professional that you may have seen before us. 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 will mail you an appointment reminder on a postcard, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

 

Examples of how we use or disclose your health information for payment purposes are: asking you about your medical 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 must 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.

 

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 specific permission. Most of these situations will never apply to you but they could.  Such uses or disclosures are:

• When a state or federal law mandates that certain health information be reported for a specific purpose
  For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
• Disclosures to governmental or law authorities about victims of suspected abuse, neglect or domestic violence
• Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
• Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else
• Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations
• Uses or disclosures for health-related research
• Uses and disclosures to prevent a serious threat to health or safety
• Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
• Disclosures of de-identified information
• Disclosures relating to worker’s compensation programs
• 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 or disclosures
• Disclosure of information needed in completing forms from a school-related vision screening, Department of Public Safety, information related to certification for occupational or recreational licenses
• Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information
• 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.

 

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES
 

It is the policy of Prime Eye Center for our staff to take phone calls from individuals on a patient’s 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.  Eye Heart Vision 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.  Prime Eye Center 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 unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. The request for signing an authorization form may be initiated by Prime Eye Center or by you as the patient. 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 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 health information. You can:

Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment, or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the Privacy Officer named at the beginning of this Notice.

Ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home/work or using some special email address. We will accommodate these requests if they are reasonable and if you agree to pay any additional costs, 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.

Ask to review or to get copies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site).  If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access or copies if we send you a written notice of the extension. 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.

Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within 60 days of your written requests 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. 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.

Obtain a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the Privacy Officer named at the beginning of this Notice.

Obtain additional copies of this Notice of Privacy Practices upon request from our business office.

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 existing health information as well as any additional information generated 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 website.

 

COMPLAINTS

If you think anyone at Prime Eye Center 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 concerns you may have in writing. If we cannot resolve your concern at the level, you may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights, or the Texas Attorney General’s Office. We will not retaliate against you if you make such a complaint.

Please read the following statements truthfully. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.

Dear Patient,

You have come to our office today for routine or medical evaluation and treatment that will be done during the COVID-19 pandemic.  Pleased be advised of the following:

• While our staff complies with the State Health department and the CDC infection control guidlines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. 

• Our staff is symptom-free and, to the best of their knowledge, have not been exposed to the virus.  However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. 

In order to reduce the risk of spreading COVID-19, we are asking you a number of screening questions below.  For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.