Mack Eye Center

Welcome to Mack Eye Center.  Thank you for choosing us for your eyecare needs.  We are delighted to have you as a patient and appreciate the confidence you placed in us.  Please take a moment to complete the following information.  All fields marked with an asterisk need to be filled out.  If you have any questions, please do not hesitate to ask.

Please note:  This form may take a few minutes to complete, so please be sure you allow yourself enough time to finish as it does not save for you to return and complete at a later date.  Thank you. 

 

Primary Insurance Information

When you come for a visit, please have your updated insurance information readily available.

If you are covered by an HMO, please make sure that you have your referral in hand at the time of your appointment.  Patients without referrals will be rescheduled until you are able to get a referral from your primary care doctor.

We wish to thank you for completing this form.  This will help us in better serving your needs.  I acknowledge that the above information is true.

Consent for Release of Confidential Information

Mack Eye Center respects the privacy of every patient and does its best to protect such information.  We will, however, release medical information to another physician when it is necessary for the treatment of our patients.  Please know that only pertinent information will be released to ensure that your privacy is maintained.

There are also times when your insurance carrier requires additional health information in order to process payment for claims.  In these instances, only the relevant information will be provided to them.   Again, we do our best to protect your health information.

I understand that Mack Eye Center has the right to release my health information for the above reasons.  I also know that they will protect my information to the best of their ability.

This consent is valid the entire length of my relationship with the Mack Eye Center.  Should I feel it necessary to revoke this notice, I understand it must be done in writing to my physician's office.

More detailed information is available upon request.

About This Notice

This notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes tht are permitted or required by law.  It also describes your rights to access and control your protected health information.  "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of your protect health information; give you this notice of our legal duties andd privacy practices with respect to your protected health information; and follow the terms of our notice that are currently in effect.  We may change the terms of our notice at any time.  The new notice will be effective for all protected health information that we maintain at the time as well as any information we receive in the future.  You can obtain any revised Notice of Privacy Practices by contacting our office.

How We May Use and Disclose Your Protected Health Information

The following examples describe different ways that we may use and disclose your protected health information.  These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.  We are permitted to use and disclose your protected health information for the following purposes.  However, our office may never have reason to make some of these disclosures.

For Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care treatment and any related services.  We may also disclose protected health information to other physicians who may be treating you.  For example, your protected healthy information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

For Payment:  Your protected health information will be used, as needed, to obtain payment for your health care services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to your health plan to obtain approval for hospital admission.

For Health Care Operations:  We may use and disclose your protected health information for health care operation purposes.  These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may use your protected health information to review the treatment and services you receive to check on the performance of our staff in caring for you.  We also may disclose information to doctors, nurses, technicians, medical students, and other personnel for educational and learning purposes.  The entities and individuals covered by this notice also may share  information with each other for purposes of our joint health care operations.

Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services:  We may use and disclose your protected health information to contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.

Others Involved in Your Healthcare:  Unlesss you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Required by Law:  We may use or disclose your protected health information to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, as required by law, of any such uses or disclosures.

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of controlling disease, injury or disability.  We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight:  We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil right laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required by law.

Legal Proceedings:  We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement:  We may also disclose your protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law; (2) limited information requests for identification and location purposes; (3) pertaining to victims of a crime; (4) suspicion that death has occurred as a result of criminal conduct; (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the practice's premises) and it is likely that a crime has occurred.  

Coroners, Funeral Directors and Organ Donation:  We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose your protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety or safety of a person or the public.  We may also disclose your protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs or your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers' Compensation:  Your protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established progams.

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

For Data Breach Notification Purposes:  We may use or disclose your protected health information to provide legally required notices of unauthorized acquisition, access, or disclosure of your health information.  We may send notice directly to you or provide notice to the sponsor or your plan, if applicable, through which you receive coverage.

Required Uses and Disclosures:  Under the law, we must make disclosure to you and when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et.seq.

 

 

 

Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information

Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV related information, alcohol and substance abuse information, mental health information, and genetic information.  Some parts of this Notice of Privacy Practices may not apply to these types of information.  If your treatment involves this information, you may contact our office for more information about these protections.

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law.   You may revoke this authorization, at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in the authorization.  Additionally, if a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, it is our intent to meet the requirements of the more stringent law.

 

You have the right to inspect and copy your protected health information.

This means you may inspect and obtain a copy of your protected health information that is contained in your designated file for as long as we maintain the protected health information.  A "designated file" contains medical and billing records and any other records that your physician and the office use for making decisions about you.  Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.  You must make a written request to inspect and copy your designated file.  We may charge a reasonable fee for any copies.  

Additionally, if we maintain an electronic health record of your designated file, you have the right to request that we send a copy of your protected health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your protected health information.  Depending on the circumstances, we may deny your request to inspect and/or copy your protected health information.  A decision to deny access may be reviewable.  Please contact our office if you have questions about access to your medical records.

You have the right to request a restriction of your protected health information.

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  This office is not required to agree to a restriction that you may request.  If this office believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted.  If this office does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction by contacting our office.

You have the right to restrict information given to  your third party payer if you fully pay for the service out of your pocket.

If you pay in full for services out of your own pocket, you can request that the information regarding the services not be disclosed to your third party payer since no claim is being made against the third party payer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

We will accommodate reasonable requests.  We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.

We will not request an explanation from you as to the basis for the request.  Please make this request in writing to our office.

You have the right to have your physician amend your protected health information.

This means you may request an amendment of protected health information about you in your designated file for as long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Please contact our office if you have questions about amending your medical record.  Your request must be in writing and provide the reasons for the requested amendment.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes.  The right to receive this information is subject to certain exceptions, restrictions and limitations.  Additionally, limitations are different for electronic health records.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

You have the right to receive notice of a security breach.

We are required to notify you if your protected health information has been breached.  The notification will occur by first class mail within 60 days of the event.  A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of your protected health information.  The notification requirements under this section only apply if the breach poses a significant risk for financial, reputational, or other harm to you.  The notice will contain the following information:  (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches.  Not every impermissible use or disclosure of protected health information constitutes a reportable breach.  The determination of whether an impermissible breach is reportable hinges on whether there is a significant risk of harm to you as a result of impermissible activity.  For example, if your protected health information was inappropriately shared with a billing clerk and she understood her confidentiality obligations, you would not need to be notified of the breach.  If we inadvertently disclosed that you received services at our facility, without more specifics, this may also not be a reportable breach because it may not have been a significant risk of financial or reputational harm.  The key to determining potential harm is whether sufficient information was released that would allow identity theft or harm you because of the likelihood of sharing sensitive health data.

 

 

 

 

Mack Eye Center's goal is to provide and maintain a good physician-patient relationship.  Advising you of our office policy in advance allows for improved communication and enables us to achieve our common goal.  Please read this policy carefully and if you have any questions, do not hesitate to ask our staff.  Thank you in advance.

- It is your responsibility to understand your health insurance plan benefits regarding all services.  According to your insurance plan, you are responsible for any and ALL co-payments, deductibles and co-insurances (due at the time of service).

-  If our physicians are out of network or you do not have insurance, payment is due in full, at the time of service.

-  Patient balances are billed immediately upon receipt of your insurance company's explanation of benefits.  Your payment is due within 30 days upon receipt.

-  Accounts with balances over 60 days past due will be turned over to a collection agency.  If your account is in collections, there will be an additional 50% fee charged to your balance.

-  If your account is in bad debt or assigned to a collection agency, NO future routine appointments will be scheduled until the balance is paid in full.

-  In an effort to serve you better, we require a 24-hour notice for canceling appointments, otherwise a $100 fee will be charged.  This NO SHOW charge is NOT reimbursable by your insurance company.  You will be billed directly.  If a 3rd no show or cancellation/reschedule with no 24-hour notice should occur, the patient may be dismissed from Mack Eye Center.  Patients arriving more than 15 minutes after their appointment time may be asked to reschedule.

-  A $30 fee will be charged for any returned checks, due to insufficient funds.

-  A refraction (a test used to measure the refractive error of your eyes) is typically not covered by medical insurance.  It is your responsibility to understand your insurance coverage and that you will be held responsible for the $55 charge, even when it is necessary for your treatment to have this test.  If you would like to opt out of this test, please let the technician know at the beginning of your exam.

-  If you have any forms for the physician to fill out, such as FMLA, Disability, etc. there is a $25 fee for completion of these forms.  Payment is due when forms are delivered.  There is a one-week turnaround time for these types of forms.  Please note:  this form must be signed for treatment and visits at Mack Eye Center.

 

Dismissal of Patients for Financial Reasons

Patients can be dismissed from the practice for a number of reasons, including the following financial situations:

1.  Collection Agency Turnover will result in a dismissal from the practice if a patient fails to pay his or her balance within the 30-day turnover.

2.  Expedited dismissal occurs when a patient is not honoring his or her financial responsibilities.  All patients should be given at least 30 days notice before being dismissed from the practice unless instructed otherwise by the physician.

 

 

Routine Eye Exams, Medical Eye Exams and Refractions

Regular eye examinations are important to maintain your vision for your lifetime.  It is important that you be aware of your insurance benefits and how they apply to your visit, so you will know how billing will be handled.  Ultimately, it is your responsibility to know what your own medical or vision plan covers.  We hope this information will help you to understand how your visit is submitted to your insurance for today's visit and future visits with Mack Eye Center.  Benefits may vary  based upon the reason for your visit.  Your description of your eye condition will help us to determine whether your visit to the clinic is defined as "Routine" or "Medical".  Your symptoms and eye examination will determine how your visit is coded and billed to your insurance.

Routine Eye Examinations - A "routine eye exam" takes place when you come for an eye exam without any medical eye problems and there are no symptoms except for visual changes.  This type of exam can be corrected with glasses or contact lenses.

Medical Eye Examinations - Your visit will be coded as a "medical eye examination" whenever you are being evaluated/treated for a medical condition, such as dry eye or cataracts.  These things often aren't determined until the doctor sees you.

Vision Service Signature Plan (VSP) and other vision plans, such as Eyemed - If you have a vision plan, we need to be aware of this coverage prior to your exam.  Vision insurance only covers routine eye exams.  If you determine that you have vision coverage after your exam has been completed, we will not bill them, but will happily provide you with the financial documentation needed for independent filing.

What is a Refraction?

A refraction is a vision test that determines your best corrected visual acuity with eyeglasses.  This is a measurement that the doctor or technician takes with an instrument called a phoropter.  It holds corrected lenses in front of your eyes.  You may hear the doctor/technician ask you, "which is better...lens one or lens two?" This test is not covered by Medical insurance, even if it is medically necessary.  The charge for this service is $55.00.  This is a routine charge for all Medical and Surgical Ophthalmologists' offices.  If you wish to forego this test, please inform us BEFORE we begin doing any testing.

I understand the difference between routine and medical eye examinations.  I understand that depending on the type of exam I have, it may go to either my Medical or my Vision insurance (if I have a vision plan).  I understand that fees may apply and I will be responsible for what is not covered by insurance.