Policy Holder

Policy Holder

FINANCIAL/INSURANCE POLICY

We have contracted with many insurance carriers and managed care networks to be providers on their plans. Contractually, both the provider and the patient have certain obligations under these plans. If you have medical insurance, we are anxious to help you receive your maximum benefits allowed. In order to achieve this goal, we ask for your assistance and your understanding of our payment policies.

• All payments for services not covered by your insurance plan, or services being filed on an insurance plan, are due at the time of service.
• WWe must have a copy of your current insurance card at the time of your visit in order to file a claim for you. If we do not have proof of a valid insurance, you will be responsible for the full amount of services rendered.
• We will collect all co-payments/or deductibles due at the time of service
• Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract and are not responsible for knowing the specific benefits of your plan.
• Verification of your benefits does not guarantee payment.
• Not all services are a covered benefit in your insurance contract. Some insurance companies select certain services they will not cover or set maximum limitations. Any services identified as such will be your responsibility and payment will be due at the time of service.

We must emphasize that filing of claims is a courtesy we extent to all our patients. All charges are your responsibility from the date of services are rendered. It is understood that temporary financial problems may affect timely payment of your account. If such problems arise, please contact us promptly for assistance in the management of your account.

PLEASE ACKNOWLEDGE YOUR UNDERSTANDING AND AGREEMENT TO THESE TERMS BY SIGNING BELOW: I hereby authorize STAR RETINA, to furnish my insurance company, its representatives or any other insurance company or attorney, the customary medical information requested about me. I understand that STAR RETINA will file my insurance on my behalf and I will be responsible for following up with my insurance company for timely payment of services rendered. I agree to pay in full all balances due that are not paid by the insurance company.

CONSENT FOR USE AND DISCLOSURE OF INFORMATION

I have reviewed the NOTICE OF PRIVACY PRACTICES of STAR RETINA. I also consent to the use or disclosure of my protected health information for the following purposes:

1. TREATMENT
   It will be necessary to share protected health information with all members of the treatment team for restatement purposes. This can included employees in this office, as well as other providers.
   
   
2. PAYMENT
   Necessary information will be shared with appropriate payer sources and their representatives for payment purposes, including but not limited to eligibility, benefit determination, and utilization review. It will also be necessary for the billing personnel, including but not limited to employees, case managers, claims representatives, third party billing services or clearinghouses to have access to protected health information to carry out their job functions.
   
   
3. HEALTHCARE OPERATIONS
   Necessary information will be shared for the continuing operations of this office. Some examples include, but are not limited to peer review, accreditation, credentialing processes, and compliance with all federal and state laws. I understand that my treatment may be conditioned upon my consent. This consent is given freely and I understand that I can revoke this consent at any time in writing, which will apply to disclosures and uses made subsequent to the revocation date.
   
   
4. DISCLOSURE OF MEDICAL INFORMATION Please list below the names of any individuals with whom you authorize members of our office staff to discuss your medical information (example: your spouse or a parent):

PATIENT REFUND POLICY

STAR RETINA strives to collect the accurate amount owed from patients for co-pays, deductibles, and co-insurance.

However, on some occasions the patient will be due a refund. In the instance of a required refund, the following policies shall apply:

• Refunds are processed for payment within 30 days of notification from the insurance provider, patient, or explanation of benefits that a refund is due to the patient.
• If the patient paid for services with a debit or credit card, we will process the refund back to that specific card. We will NOT issue checks for credit or debit card refunds.
• If the payment was made with a check or cash, we will provide the refund in the form of a paper check and mail to the patient’s last known address.

PATIENT HISTORY QUESTIONNAIRE

STAR RETINA - NOTICE OF PRIVACY PRACTICES

Protecting Your Privacy

Protecting your privacy and medical information si at the core of our practice. We recognize our obligation to keep your information (both written and digital) secure and confidential. AT STAR RETINA, your privacy is one of our highest priorities.

Keeping Your Information

Our employees access information about you only when necessary to provide treatment, determine eligibility, obtain authorization, process claims and otherwise meet your needs. We may access your information when considering a request from you, when exercising our right under the law, or any agreement with you. We safeguard information during all business practices accordingly to established security standards and procedures, and we continually assess technology for protecting information. Our employees are trained to understand and comply with these information principles.

Working to Meet Your Needs Through Information

In the course of doing business, we collect and use various information, such as name, address and claims information. We use this information to provide service, process claims and provide health information that might be of interest to you. Keeping your health information accurate and up-to-date is very important. If you believe health information we have about you is incomplete, inaccurate or not current, please inform us immediately. We take appropriate action to correct any erroneous information promptly through standard set of practices and procedures.

How and Why Information is Shared

We share information within our practice to deliver you health care services, related information and education programs specified to your care. To help us offer you our services, we may share information with companies that work for us, such as claims processing, mailing companies and companies that deliver health information directly to you. These companies act on our behalf and are obligated contractually to keep this information confidential. Patient-specific personally identifiable data is released only when required to provide a service for you and only to those with a need to know, or with your consent. Data is released with the condition that those receiving the data will not, without your permission, release it further. If we receive a subpoena or similar legal process demanding release of your information, we will attempt to notify you (unless we are prohibited from doing so). Except as required by law or as described above, we do not share information with other parties including government agencies. STAR RETINA does not share any customer information with third-party marketers who offer their products and services to our patients.

Count On Our Commitment To Your Privacy

You can count on us to keep you informed about how we protect your privacy and limit the sharing of information you provide to us – whether its our office, the phone or the internet.

You have the right to obtain a paper copy of this notice from us, upon request.

Patient Acknowledgement of Receipt of Privacy Practices