NOTICE OF PRIVACY PRACTICES

Effective Date: September 23, 2013

Diana Tran, O.D. ● (540) 300-2771

 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.

 
Your medical record may contain personal information about your health. This information may identify you and relate to your past, present or future physical or mental health condition and related health care services and is called Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

 
How we may use and disclose health care information about you:

 
For Care or Treatment: Your PHI may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care. Example: If another physician referred you to us, we may contact that physician to discuss your care. Likewise, if we refer you to another physician, we may contact that physician to discuss your care or they may contact us.

 
For Payment: Your PHI may be used and disclosed to any parties that are involved in payment for care or treatment. If you pay for your care or treatment completely out of pocket with no use of any insurance, you may restrict the disclosure of your PHI for payment. Example: Your payer may require copies of your PHI during the course of a medical record request, chart audit or review.

 
For Business Operations: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. We may also disclose PHI in the course of providing you with appointment reminders or leaving messages on your phone or at your home about questions you asked or test results. Example: We may share your PHI with third parties that perform various business activities (e.g., Council on Accreditation or other regulatory or licensing bodies) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

Required by Law: Under the law, we must make disclosures of your PHI available to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, if so required.

 
Without Authorization: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. Examples of some of the types of uses and disclosures that may be made without your authorization are those that are:

Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the health department)
Required by Court Order
Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

 
Verbal Permission: We may use or disclose your information to family members that are directly involved in your receipt of services with your verbal permission.

 
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your explicit authorization is required to release psychotherapy notes and PHI for the purposes of marketing, subsidized treatment communication and for the sale of such information.

 
Your rights regarding your PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer:

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances or with documents released to us, to inspect and copy PHI that may be used to make decisions about service provided.
Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for services, payment, or business operations. We are not required to agree to your request.
Right to Request Confidential Communication. You have the right to request that we communicate with you about PHI matters in a specific manner (e.g. telephone, email, postal mail, etc.)
Right to a Copy of this Notice. You have the right to a copy of this notice.

Website Privacy

Any personal information you provide us with via our website, including your e-mail address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site.

 
Our site may contain links to other outside websites. We cannot take responsibility for the privacy policies or practices of these sites and we encourage you to check the privacy practices of all internet sites you visit. While we make every effort to ensure that all the information provided on our website is correct and accurate, we make no warranty, express or implied, as to the accuracy, completeness or timeliness, of the information available on our site. We are not liable to anyone for any loss, claim or damages caused in whole or in part, by any of the information provided on our site. By using our website, you consent to the collection and use of personal information as detailed herein. Any changes to this Privacy Policy will be made public on this site so you will know what information we collect and how we use it.

 
Breaches:

You will be notified immediately if we receive information that there has been a breach involving your PHI.

 
Complaints:

If you believe we have violated your privacy rights, you are free to complaint to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to our Privacy Officer.

 
Contact Person:

You may contact our Privacy Officer, Diana Tran, O.D. at 14050 Worth Ave, Woodbridge, VA 22192 for further information about our privacy practices.

Consent To Treatment, Statement Regarding Treatment Outcome Patient hereby voluntarily consents to the care encompassing examination, diagnostic procedures, and treatment by The Doctor (collectively defined as: Eyc Doctor Office, Inc., Diana Tran OD. or Diana Tran, O.D as are necessary or beneficial in judgment of The Doctor. Patient agrees to follow The Doctor's instructions and fully participate. As an assurance. The Doctor offers free prescription recheck between 30 and 60 days after the exam: special non-visual management is not included but will be required at The Doctor's discretion. This free recheck does not apply to Patient who presents with diabetes, recent ocular surgery. recent ocular injury. red eyes, discharge. inflammation, unusual presentation, or those we refer out. Patient who has or had been seeing an eye specialist and wants better corrected visual acuity than what's obtained at the last visit must bring the specialist's report: if Patient did not bring it on the initial visit, Patient must bring it at the recheck. The Doctor will explain procedures, diagnostic results. prognosis, counseling on risk factors, risk/benefit and side effects of management options, management instructions, important of compliance with chosen management options. If The Doctor is not clear with the explanation, Patient will ask until Patient is fully informed By acceptingthe management plan, Patient acknowledges that he/she has been fully informed and he/she voluntarily given informed consent to the plan. Patient understands that in the event he/she is not satisfied with the new spectacle prescription, he/she will get a referral instead of a spectacle prescription. Acceptance of the spectacle prescription constitute complete satisfaction by the Patient. By not scheduling an appointment with the Doctor or with a referred doctor for the recommended care, Patient had declined further evaluation and management from the Doctor or the referred doctor respectively.

Authorization to Release Medical Information Patient authorizes the Doctor to release any information necessary to determine benefit, process the claim and/or collect fee. Patient requests payment of benefit to the Doctor and/or its business associates. This authorization does not apply if Patient had already paid in full out of pocket. Financial Policy The Doctor hereby agrees to render optometric care and services to Patient. Patient agrees to pay estimated deductible, copay. & non- covered services fee at time of service. The Doctor determines due date, estimated amount and payment methods. Professional fees are non-refundable. Patient and/or responsible party agree to be responsible for payment of his/her account to The Doctor or its assign. It is the Patient's responsibility to provide The Doctor with the most current contact information. Question about statement must be sent to The Doctor's email at info@geteyeexam.com or mailing address. Dispute the validity of the balance, however, must be sent to The Doctor's mailling address. Payment in full is due by the due date printed on the statement. Patient balances not paid in full by due date are deemed past due. At The Doctor's discretion, past due accounts may be referred to a collection agency and/or attorney forfurther collection activity. The Doctor shall be entitled to collect expenses, including but not limited to collection agency fee (which may be based on a percentage at a maximum of 40% of the debt all costs and attorney's fees incurred in the collection. In the event Patient initiates a credit card dispute. retrieval, or chargeback, Patient agrees to be responsible for a $40 research fee.

Termination The doctor-patient relationship is maintained between The Doctor and Patient as long as Patient continues to receive treatment from The Doctor. If Patient cancels or does not show up for his/her appointment, and Patient does not contact The Doctor within three months of the last appointment, The Doctor will assume that Patient no longer want to be under its care. At which time, The Doctor will no longer be responsible for Patient's eyecare. The doctor-patient relationship will be terminated as evidenced by three months of no contact from Patient.

Terms for Contact Lens Patient Basic/Standard contacts (CL) fit does not include follow up and is for patient who want the same exact contacts without any further reconsideration, and/or change in any parameter (power, brand, base curve, diameter Premium/Non-basic contacts fit includes upto 2free follow ups and might be required at the Doctor's own discretion when there is a re-evaluation, reconsideration, and/or change in any parameter (power, brand, base curve, diameter Special management of signs or symptoms of a problem is not covered. Eye exam is required on the same date. At any given time, if the Patient presented with any signs and/or symptoms of a non-infectious problem but Patient did not get for the medical evaluation and management from the Doctor, Patient promised to seek medical eye care elsewhere immediately. It is understood that if Patient did not pay the professional fee for the medical evaluation and management at check-in, he/she will not get that service. Qualification for contacts use will be determined by the Doctor. Patient will be asked to select CL type (spherical, toric, mono, bifocal) and disposable type (daily, weekly, biweekly, etc However, for Patient who has certain eye problem, The Doctor will do the selection. Type change requires a new fitting. Number of trials and follow ups are set by The Doctor. All follow ups are required. Patient agrees to report any problems, CL related or not, before a prescription is released. The follow up period is 60-day from the day patient were given the initial trials. Past that 60 day. patient will be charged the full eye exam and contact exam fee. For it to be considered a free follow up. Patient must wear the last given non-expired trial CL for at least 2 hours immediately prior to and to each follow-up: failure to do so, the follow up is no longer free. If Patient fails to make and keep the

required follow up, Patient does not have a CL Rx. Prescription acceptance constitutes complete satisfaction by the Patient. If Patient paid, patient had agreed to the fee. Each additional follow up: $30. (Uninsured gets the discount as listed; insured: usual and customary fee will be apply and the discount will be removed Fee is non-refundable even if Rx is not finalized. Arbitration Provision It is the intention of the parties to resolve all disputes as cordially and efficiently as possible. Any controversy. dispute, or claim ("Claims") arising out of, in connection with, or in relation to the interpretation, performance or breach of this Agreement shall finally be resolved by binding arbitration conducted in Fairfax County, Virginia. All Claims are subject to arbitration, no matter what legal theory they are based on or what remedy. Any questions about whether Claims are subject to arbitration shall be resolved by interpreting this arbitration provision in the broadest way the law will allow it to be enforced. Both parties understand that they are giving their constitutional right to a trial in court by a judge or jury, and the right to appeal concerning any disputes. The arbitration shall be conducted on a confidential basis pursuant to the Commercial Arbitration Rules of the American Arbitration Association (the "Association" Each party shall choose one arbitrator and the two arbitrators shall choose a third arbitrator. The arbitrators shall be licensed optometrists who actively engaged in the practice of Optometry and its business practices in the Commonwealth of Virginia. This arbitration provision shall not apply to either The Doctor or patient in any disputes pertaining to collections. Patient understands that this agreement binds him/her, his/her non-signing spouse, his/her heirs, or personal representative on one hand and The Doctor, and its corporation, limited liability company or partnership, if any, and its employees, agents, partners. officers, directors, members, contractors, heirs, assigns, or personal representatives, and any substitute doctor on the other hand. Any award entered by the arbitrator shall become final, binding. and not subject to appeal. Judgment may be entered thereon by either party in accordance with applicable law in any court of competent jurisdiction. This arbitration provision shall be specifically enforceable. The arbitrator shall have no authority to modify any provision of this Agreement or to award a remedy for a dispute involving this Agreement other than a benefit specifically provided under or by virtue of the Agreement. The prevailling party shall be awarded all costs, including reasonable attorney's fee, the Arbitrator fees, costs of subpoenas, depositions, transcripts and the like, in prosecuting or defending the claim in arbitration. Furthermore, if any action is undertaken to set aside or otherwise attack the binding arbitration award, the losing party in the court action shall bear all the prevailling party's costs. including reasonable attorney's fees. The prevailing party shall be determined by comparing the amount awarded with the last settlement position of the respective parties.

Other Policies Patient authorizes The Doctor to contact him/her at any collected contact information, not limited to today's. The Doctor maintains record for five years from last encounter. Patient's electronic recording is strictly prohibited. Entire Agreement This Agreement sets forth the entire agreement between the parties hereto relating to the subject matters herein, and fully supersedes any and all prior agreements or understanding between the parties hereto, if any, pertaining to the subject matter hereof.

Miscellaneous This Agreement is retroactive and governs all past and future services The Doctor has previously or may later perform for Patient. This Agreement may not be changed, crossed out, waived, discharged or terminated by any means except by an agreement in writing signed by a party against whom enforcement of the change. cross out, waiver, discharge or termination is sought. Failure by either party to strictly enforce any term of this Agreement shall not constitute waiver of such term. In the event that any part of this Agreementis deemed unenforceable, the remainder of this Agreement shall be valid and enforced. A photocopy of this Agreement is to be considered as valid as the original. Patient acknowledges that he/she received a copy of the Agreement. Patient has been given the opportunity to ask questions and receive satisfactory and adequate explanations. Patient is not in need of emergency care or under immediate stress. It is understood by the Patient that he or she is not required to use The Doctor for optometric services and that there are numerous other optometrists in Northern Virginia area who are qualified to perform optometric services.

IN WITNESS WHEREOF. the Parties have set their hands on

Most people have vision insurance and medical insurance. They are very different in terms of the services they cover and it's important for Patient to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses and is not equipped to deal with complex medical conditions and/or diagnoses. It does allow for screenings of conditions, but once they are determined, then medical insurance is filed on those services. When a medical conditionis present (such as diabetes, cataracts, dry eye, floaters, etc it is necessary to file the visit with Patient's major medical carrier and the co-pays for that insurance will apply. Insurance carriers set these rules and Diana Tran, O.D. and/or her associates (the Doctor) is required to follow them. In most cases, there is no way to know prior to the examination which type of insurance the Doctor will be able to file for the Patient.

1. If Patient has ANY problems or complaints that MAY be attributable to a medical condition which requires a morein- depth investigation and additional medical decision-making to rule out any underlying eye disease, the Doctor will accordingly bill Patient's MEDICAL insurance, NOT Patient's vision plan. These include, but are not limited to: new or sudden blurry vision, eye pain or redness, flashes or floaters, headaches, dry or itch eyes, loss of vision, eyestrainor double vision.

2. There are a variety of systemic conditions that can profoundly and permanently affect a patient's vision that requirea more in-depth investigation, which may include additional testing, follow up visits, and reports to your primary care physician. This type of examination is NOT covered under "vision" plans, and the Doctor will bill Patient's MEDICAL insurance, NOT Patient's vision plan. These include, but are not limited to: diabetes. lupus or autoimmune disease, hypertension, thyroid disease, diseases resulting in use of high risk medications like Plaquenil.

3. If Patient has previously been diagnosed by another eye doctor for any eye issues that require medical decision-making, treatment or management, the Doctor will bill Patient's MEDICAL insurance, NOT Patient's vision plan. These include, but are not limited to: cataracts, macular or retinal disease, amblyopic/lazy eyeglasses. history of eye surgery. glaucoma/previous diagnosis of high eye pressure.

The Doctor makes every effort to be on every major carrier for Patient's conveniences and the Doctor will file those claims for the Patient. In the event that the Doctor do not take your insurance the Doctor will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If Patient has any questions. please let the Doctor know.

Patient understands the information he/she has just read. Patient authorizes Diana Tran, O.D. and/or any business she is associated with to file Patient's insurance by the above guidelines. This agreement governs today and future services. Patient further agrees that a photocopy of this agreement shall be as valid as the original.