White Eye Care - Patient Forms

White Eye Care - Patient Forms
POLICY FOR MEDICAL VISITS

Medical visits include examination and treatment for infections, injuries, allergies, headache, eye pain, diabetic eye care and eye disturbances other than Routine eye exams, eyeglasses and contact lenses.

Medical visits and medical insurance coverage are separate from optical coverage. Medical visits are covered by outpatient medical insurance, the same as visits to a family doctor. These visits are not optical, and should be covered regardless of whether the insurance includes optical coverage, which may allow an eye exam every one or two years.

For example:
If you see Dr. White for a medical visit, our staff will gladly file a claim with your insurance carrier. There is no charge for the initial filing. However, if it is necessary to re-file, or file with a second insurance carrier, there is a charge of $5 for each additional filing.

IF THE INSURANCE CARRIER, FOR ANY REASON, HAS NOT PAID THE CHARGES WITHIN 60 DAYS FROM THE DATE OF SERVICE, THE CHARGES ARE DUE FROM THE PATIENT OR GUARDIAN.

THE CHARGES ARE YOUR RESPONSIBILITY. IF THERE IS A PROBLEM WITH YOUR INSURANCE, YOU MUST PAY THE CHARGES AND PURSUE THE PROBLEM WITH THE INSURANCE CARRIER. IT IS SIMPLY IMPOSSIBLE FOR US TO PURSUE THESE MATTERS WITH INSURANCE COMPANIES.

If you have no medical insurance, and cannot afford to pay, you must notify Dr. White, or his staff before the services are rendered. Every attempt will be made to provide the services needed. If we are not notified before services are rendered, we will pursue collection of charges.

If for any reason you are sent to a collection agency, an additional 30% late charge will be added to your account balance for late fees.

I have read and agree to the terms stated above. I agree to pay any charges not paid by the insurance carrier within 60 days, regardless of the reason the insurance carrier does not pay promptly.
Name *

First Name Last Name
Date *

Month Day Year
Date
Signature of patient or guardian *

Clear
Social Security Number

HIPAA Notice of Privacy Practices

WHITE EYE CARE CENTER, INC
407 GEORGE KOST AS DRIVE
LOGAN, WV 25601
(304) 752-2020
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.

This Notice of Privacy Practices dacribes how we may use, and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that 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.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health 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.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health infonnation to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health infonnation, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These siwations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicateded in the authorization.

Your Rights
Following is a statement of your rights with respect to your protected health infonnation.

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

Your physician is not required to agree to a restriction that you may request. lf physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

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

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

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

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April l4, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to
speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:
Name *

First Name Last Name
Date *

Month Day Year
Date
Signature of patient or guardian *

Clear

Patient *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
I have been made aware of the Notice of Privacy Practices, and understand that it Is available to me for review. Please initial here: *
Release of Information
I authorize White Eye Care to release of information including the diagnosis, records; examination rendered to me and claims information. *

Authorize Information is not to be released to anyone .
This information may be released to spouse:

First Name Last Name
This information may be released to child(ren):

First Name Last Name
First Name Last Name
Other:

First Name Last Name
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call

Area Code Phone Number
If unable to reach me:

you may leave a detailed message please leave a message asking me to return your call
The best time to reach me is (day)
between (time)
For written communication it is ok to:

Send mail to my home address Send a text to my phone number
Patient or Person signing on behalf of patient *

Clear
Date *

Month Day Year
Date
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to Patient
Name

First Name Last Name
Source of Authority

Patient Questionaire and Authorization Form

If I receive Medicare benefits, I certify that the Information given by me in applying for payment under Title XVIII of the Social Security Act. is correct. l authorize any holder of medical or other informatlon about me to release to the Social Security Administration's intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf.
Patient or Person signing on behalf of patient

Clear
Relationship
Notice of Exclusions From Medicare Denefits (NEMB)

There are items and services for which Medicare will not pay.
- Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits. Some items and services are not Medicare benefits and Medicare will not pay for them.
- When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it, personally or through any other insurance that you may have.
The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you will have to pay for them yourself. Before you make a decision, you should read this entire notice carefully.

Ask us to explain, if you don't understand why Medicare won't pay.

Ask us how much these items or services will cost you (Estimated Cost: $40.00).

Medicare will not pay for: REFRACTION
1. Because it does not meet the definition of any Medicare benefit.
2. Because of the following exclusion from Medicare benefits: Routine eye care, eyeglasses and examinations.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND AGREE TO PAY FOR MY REFRACTION TODAY.
Patient or Person signing on behalf of patient

Clear
Relationship
Assignment of Benefits and Authorizaion for Release of Information:
I hereby irrevocably assign to, and direct the following company
to pay to White Eye Care Center, Inc. all sums of money, except medical and surgical benefits, now or hereafter payable to me or for my benefit under the above described policy or policies of insurance as a result of the illness, or injury described hereof, to the extent of the total charges shown hereon; and I do hereby assign to, and direct said company or companies to pay to White Eye Care Center, Inc.
and/or (company name)
all surgical and medical benefits payable to me therefrom as e result of such llness or injury to the extent of his or their medical services rendered. I agree to pay to White Eye Care Center, Inc.
and/or (company name)
all charges in excess of those paid by the Insurer(s) hereunder. I also authorize White Eye Care Center, Inc. or the physician who has or will attend me to release any of my medical records to my insurance company or other third party payors responsible to pay for my treatment.
Patient or Person signing on behalf of patient

Clear
Relationship

Consent to Treatment:
I authorize and consent to that care which is necessary or beneficial, including, but not limited to, the administration of medications, injections, x-ray examinations, laboratory procedures and hospital services. I understand that the treating physician(s) is self employed, but has/have the right to practice at White Eye Care Center, Inc., I further understand that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees are made to the results of procedures performed or treatments received at White Eye Care Center, Inc.

I give my permission to White Eye Care Center, Inc. and its authorized person(s) and physicians to treat me, and give permission to students who may be participating in the Office/Hospital sponsored educational programs to observe, participate and/or be aware of the treatment and medical services which are rendered to me.

I have been advised and understand it is White Eye Care Center, Inc. policy that, for my health and protection, as well as the protection of other patients, office employees and visitors, I will not be permitted to have weapons, personal drugs, alcoholic beverages or unauthorized electrical appliances with me while I am in the office. I have been advised that such items in my possession will be inventoried and secured until such time as I am discharged from the office, when I may claim them. I agree that I will not keep any of these items in my possession during my office visit and agree and consent to a search of my possessions and person at any time, provided that there is a reasonable belief that such items may be present.

To the extent my care involves any medical devices required to be tracked under the Safe Medical Device Act, I hereby authorize the release of that information requested by the Act, includlng my Social Security number. I understand that the release of that information will be to those entities and for those purposes authorized by the Act.
Patient or Person signing on behalf of patient *

Clear
Relationship
Date *

Month Day Year
Date

Medical History Questionnaire
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Date
Email
example@example.com
Social Security Number
Guardian (If Applicable):
Phone Number *

Area Code Phone Number

Work Phone

Area Code Phone Number
Last Eye Exam *

Month Day Year
Date
Occupation *
Name of Medical Doctor *
Doctor's Phone Number *

Area Code Phone Number
Last Medical Exam

Month Day Year
Date
Marital Status

Single Married Divorced Widow