POLICY FOR EYEWEAR AND CONTACT LENSES

All sales of prescription and non-prescription eyeglasses, sunglasses, and contact lenses are FINAL. If there is a need for the prescription to be adjusted, such changes are included at no charge for a one-time redo within 90 days of purchase. All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of 6 months from the date of purchase. If the patient does not pick them up within that time frame, they will be donated to charity and no refund will be issued.

PERSONAL CHECKS AND BOUNCED CHECKS

Any bounced personal check is subject to a fee of $35, which is to be paid, in addition to the original amount, within 30 days. After the 30 day period has expired the check will be turned over to the county attorney for collection.

 

By signing below, you are agreeing to have read and understood all aspects of the above policies.

I, the patient or authorized representative, consent to any examination, evaluation, or treatment regarding any eye disorders or diseases. Evaluation and treatment may include tests such as: OCT (Optical Coherence Tomography) scans, OPTOMAP pictures, refractions, or pressure checks.

I have read and understood this agreement. I am the patient, parent of a minor child, or the legally authorized representative of the patient and I am authorized to act on behalf of the patient and sign this agreement.

                                               HIPAA

HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. HIPAA is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient'sconsent or knowledge. HIPAA protects information, such as: names, birth dates, address, telephone numbers, medical records, and insurance information.

                                          Signature on File

I authorize the release of any medical records or other information necessary to other healthcare providers or process claims.

Notice of Privacy Practices: Patient Acknowledgement

I have had the opportunity to receive this practice's Notice of Privacy Practices. The notice provides the use and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise those rights, and the practice's legal duties with respect to my protected health information. I understand that the practice may change the terms of its Notice of Privacy Practices and that any changes reapply retroactively to information created while the current notice is in effect. I understand I can obtain this practice's current Notice of Privacy Practices upon request.

                                             Financial Policy

As a courtesy to our patients, we file most vision and medical insurance claims. I understand that I am financially responsible for all charges incurred in the event that my insurance denies payment. I also understand that any services not covered by Medicare or other insurers that I am responsible for, payment will be collected at the time of service.

I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS ANY CLAIM. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE PHYSICIAN FOR SERVICES RENDERED.

                                          Review and Sign

1.I have been provided with the financial policy.

2.I have had the opportunity to receive the Notice of Privacy Practices.

3.I hereby give my consent to Family Eyecare to evaluate and treat the patient below.

4. I understand that my personal health information will be used for treatment, payment, and the coordination of health care needs of that patient.

5. I have been informed of HIPAA and I understand my personal information is protected from disclosure (without consent) by federal law.

Do hereby authorize the following individuals (must be over the age of 18) to schedule appointments, and/or accompany my children to medical appointments. Please list anyone other than the child's mother, father, or guardian who may be accompanying the child to appointments. This may include siblings over the age of 18, grandparents, babysitter, step-parents, neighbors, etc. I understand that only my child's mother, father, guardian, and/or those listed below have the authority to authorize treatment.

 

I have read all the information above and have completed the above answers. I certify that this information is true and correct to the best of my knowledge. It is the policy of this office that the adult presenting the child for treatment is responsible for the payment of the patient portion at the time of service.