Patient Intake Form

Notice of Privacy Practices: This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully. Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services. Our practice is legally required to maintain the confidentiality of your PHI, and to follow specific rules when using or disclosing this information. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules when using or disclosing your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under the Privacy Rule: Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are required by law to follow the terms of this Notice. We reserve the right to change the terms of the Notice, and to make the new Notice provisions effective for all PHI that we maintain. We will provide you with a copy of our current Notice if you call our office and request that a revised copy be sent to you in the mail, or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location in the practice, and if such is maintained, on the practice’s web site.

You have the right to authorize other use and disclosure - This means we will only use or disclose your PHI as described in this Notice, unless you authorize other use or disclosure in writing. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/ phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and obtain a copy your PHI* - This means you may submit a written request to inspect or obtain a copy of your complete health record, or to direct us to disclose your PHI to a third party. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable, cost-based fee for paper or electronic copies as established by federal guidelines. We are required to provide you with access to your records within 30 days of your written request unless an extension is necessary. In such cases, we will notify you of the reason for the delay, and the expected date when the request will be fulfilled.

You have the right to request a restriction of your PHI* - This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You have the right to request an amendment to your protected health information* - This means you may sub- mit a written request to amend your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability* - You may submit a written request for a listing of dis- closures we have made of your PHI to entities or persons outside of our practice except for those made upon your request, or for purposes of treatment, payment or healthcare operations. We will not charge a fee for the first accounting provided in a 12-month period.

You have the right to receive a privacy breach notice - You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

* If you have questions regarding your privacy rights, or would like to submit any type of written request described above, please feel free to contact our Privacy Manager. Contact information is provided at right under Privacy Complaints.

How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health- care services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.
Healthcare Operations - We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests, to provide information that describes or recommends treatment alternatives regarding your care, or to provide information about health-related benefits and services offered by our office.

Health Information Organization - The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation), then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written authorization, or providing you an opportunity to object, for the following purposes: if required by state or federal law; for public health activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or domestic violence; to avert a serious threat to health or safety; for research purposes; in response to a court or administrative order, and subpoenas that meet certain require- ments; to a coroner, medical examiner or funeral director; to respond to organ and tissue donation requests; to address worker’s compensation, law enforcement and certain other government requests, and for specialized government functions (e.g., military, national security, etc.); with respect to a group health plan, to disclose in- formation to the health plan sponsor for plan administration; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints You may ask questions about your privacy rights, file a complaint, or submit a written request (for access, restriction, or amendment of your PHI or to obtain a disclosure accountability) by notifying our Privacy Manager at: hello@atlanticeyect.com, 1031 Farmington Ave., Suite 101, Farmington, CT 06032 or via phone at 8602594603.

Consent to electronic communication: I hereby consent and state my preference to have my physician, Dr. Paula Feng, Atlantic Eye Physicians, PLLC, and other staff at Atlantic Eye Physicians communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

I understand that email and standard SMS messaging may not be completely confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.

WELCOME TO OUR PRACTICE! At Atlantic Eye, we provide the best possible care and service to you. We regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. To reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy.

REFRACTIVE TESTING (Glasses prescriptions): A refraction is performed to measure your prescription for glasses. A refraction is also an important tool that aids in the diagnosis and treatment of many eye conditions (e.g., cataracts). However, Medicare and the majority of medical insurance plans consider a refraction a "Non- Covered" Service and require that patients be responsible for payment. Federal guidelines require that refractions be billed separately for all patients. If you wish to have your glasses checked, vision checked for new glasses or other procedures, please be aware that you will be charged a fee for the refraction cost. This is payable at the time of service. There is a nominal $50 for the service and time it takes to verify and provide an accurate glasses prescription.

YOUR INSURANCE: Your visit is filed with the carrier for whom our practice has a valid contract with. It is your responsibility to provide accurate insurance and personal information including any preferred laboratory cards. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit. You will be responsible at the time of service for the payment of copays, unpaid deductibles, and past due balances.

NON- COVERED SERVICES: If a service is not covered, you will be responsible for those charges according to your benefits plan. You understand that you accept full financial responsibility for all items or services that are not covered by my insurance plan. Payment for these services is due upon arrival at your visit.

NO SHOW/CANCELLATION POLICY: We understand that unexpected events, illnesses, etc occur. When this happens, call our office as soon possible to inform us of such issues. In the case of missed appointments or cancellations within 24 hours of the appointment:

a)     Office Visit- By signing this agreement, you understand that it is your responsibility to cancel your appointment 24 hours in advance of your appointment time and date, otherwise a $45 fee will be billed to your account which is not covered by my insurance plan.

b)     Surgery appointments- By signing this agreement, you understand it is your responsibility to cancel or change your appointment at least 7 days prior to your appointment time and date, otherwise a $250 fee will be charged to your account which is not covered by my insurance plan.

Repeated no-shows and cancellations may result in being discharged from the practice.

REQUESTS FOR MEDICAL RECORDS/FORMS: Available at a fee dependent upon chart volume. Medical records may be sent to another provider at no charge electronically or by fax. If records must be printed, a $0.03 charge per page will apply to cover printing costs and administrative time for compiling them.

SELF-PAY Self-Pay Payment is expected at the time of visit unless other arrangements have been made with the office manager prior to the visit.

SIGNATURE ON FILE, ASSIGNMENT OF BENEFITS

MEDICARE PATIENTS: I request that payment of authorized Medicare benefits be made on my behalf to Atlantic Eye Physicians, for services furnished me by Atlantic Eye Physicians. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Atlantic Eye Physicians accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

MEDIGAP: I understand that if a Medigap policy or other health insurance is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of the authorized secondary insurance benefits be made on my behalf to Atlantic Eye Physicians, if possible or otherwise to me.

RELEASE OF INFORMATION: I authorize Atlantic Eye Physicians to release any medical information necessary to process my claims. This includes any information pertaining to my financial ledger, alcohol or drug abuse, psychiatric illness, communicable disease, or HIV to any person/corporation to which Atlantic Eye Physicians is liable/under contract with for reimbursement of services rendered and healthcare provider for continued patient care. I also authorize any payment of medical benefits to Atlantic Eye Physicians for services performed.

CREDIT CARD ON FILE: Recent changes in healthcare markets have altered insurance coverages to shift more of the cost of care to our patients. Many policies have higher deductibles which means, even if a procedure is covered by insurance, you may still receive a bill.  These external factors make it necessary for Atlantic Eye Physicians to maintain a credit card on file for all commercially insured patients. The card information is stored with security--the same HIPAA compliant software that protects your confidential medical information. Should you have a balance after your visit, we will mail out two statements, if no payment is received after 60 days we will bill the card on file. By signing this form you authorize Regional Dermatology to bill your card on file. Receipt of any transaction will be forwarded to the home address in our records.

I understand that the authorizations stated will remain in force until terminated in writing by the me.