Newcastle Vision Clinic is committed to protecting the confidentiality of your medical information and is required by law to do so. The Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations, and for other purposes that are permitted and required by law. It also describes your rights to access and control your protected health information. We ask for your consent to use and disclose your PHI, as outlined in our Notice of Privacy Practices, by asking you to sign the Consent for Treatment form regarding your care. Generally, unless specifically allowed by state or federal regulations without an authorization. Newcastle Vision Clinic will seek a signed authorization from a consumer or personal representative before disclosing PHI to a third party

 

USES AND DISCLOSURES Newcastle Vision Clinic may use or disclose your protected health information as follows:

Uses and Disclosure with your Permission: Uses and disclosures of PHI will generally only be made with your written permission, called a “Release of Information”. You have the right to revoke a Release at any time.

For Treatment: Our office will use and disclose your PHI to provide and coordinate your health care and any related services. We may also disclose your PHI to another health care provider working outside of our office for purposes of your treatment.

For Payment: Our office may use and disclose PHI about you for the purpose of determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company or a third party payer, or its agent. You may request restriction of this if paying for your own services.

For Health Care Operations: Our office may use and disclose PHI about you in order to support quality improvement and other business activities of our organization. These uses and disclosures are necessary for our operations and ensure the quality of care received by our patients.

Other Uses and Disclosures Provided by Law without Authorization: Our office may use and disclose PHI about you for other purposes and to other individuals and entities without a signed authorization, as provided by state and federal law. This includes but is not limited to court orders, child abuse reporting, adult protective services reporting, etc.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding your protected health information (PHI):

-Right to inspect and have paper/electronic copy

-Right to request confidential communication

-Right to request an Amendment

-Right to request restrictions

-Right to a paper copy of Notice

-Right to an accounting of certain disclosures

-Right to be notified of breach of unsecured PHI

To file a violation complaint with our office, contact our office manager or the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be retaliated against for filing a complaint.

 

In addition to this summary, you are being offered a full detailed copy of the Notice of Privacy Practices. You may also at any time receive a copy by asking for one when you are at our office or request for one to be mailed to you.

Please read and sign below:

We will be happy to bill your insurance for you as a courtesy provided that you bring your insurance card with you to your visit. You may also submit insurance claims yourself. We must also emphasize that as your eye care providers, our relationship is with you, not your insurance company, with whom we have no legal relationship. While the filing of insurance claims is a courtesy we extend to our patients, all charges (deductible amount, co-insurance, or any balance not paid by your insurance company) are your responsibility from the date the services are rendered. All copays are due at time of appointment. All benefits quoted are not a guarantee of payment by your insurance company and final determination can only be made when the claim is processed. If your insurance company has not reimbursed our office in full within 90 days, you will be responsible to pay for those office fees. If we are not billing your insurance, you are financially responsible for all services from the date the services are rendered. Questions or concerns regarding charges, insurance coverage or benefits will be addressed with the office manager or any other staff members, not with the doctor. I acknowledge that I have completed all of the information to the best of my knowledge. I authorize the eye doctor to release any information about my records to pertinent third party payers and/or other health practitioners if needed. I understand that returns and/or exchanges of any eyewear, as seen necessary by a staff member, will be done so by office credit and no refunds will be given. Any eyewear returns or exchanges may be subject to a restocking fee.

On the next page, please complete your demographic and medical history information. Thank you!