Medicare Agreement: I request that payment of authorized Medicare benefits be made on my behalf to EyeSight Medical Center for services provided me by Dr. Nicholas Stathopoulos, M.D. I authorize any holder of Protected Health Information about me to be released to CMS (formerly Health Care Financing Administration) and its agents any information needed to determine these benefits or the benefits payable to related services.
• I understand my signature requests that payments be made and authorize release of Protected Health Information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFA 1500 forms or elsewhere on other approved claim forms, my signature authorizes the release of information to the insurer or agency shown.
• EyeSight Medical Center accepts the charge determination of the Medicare carrier as the full payment. The patient is responsible only for the deductible, co- insurance, and non-covered services. Co-insurance and deductible are based upon the charge determination of the Medicare carrier.
MediGap:
• I understand that if a MediGap policy or other health insurance policy is indicated in Item 9 of the HCFA 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 authorized secondary insurance benefits be made on my behalf to EyeSight Medical Center.
Third Party Payers:
• I understand that EyeSight Medical Center maintains a list of healthcare service plans with which it contracts. A list of such plans is available from the business office and that EyeSight Medical Center has no contract, expressed or implied, with any plan that does not appear on this list. I agree that I am obligated to pay the full charges of all services rendered to me by EyeSight Medical Center if I belong to a plan that does not appear in the above mentioned list.
Non-Covered Services:
• I understand EyeSight Medical Center contracts with health insurance plans (i.e. HMO's, PPO's) which state items that are deemed to be "covered" by the health plan. Accordingly, I accept full financial responsibility for all items, services, or tests which are determined by the health plan not to be covered. I agree to cooperate with EyeSight Medical Center to obtain necessary health care insurance plan authorizations.
Financial Agreement:
• I agree that in return for services provided to the patient by EyeSight Medical Center I will pay my account at the time service is rendered or will make financial arrangements, which are satisfactory to EyeSight Medical Center for payment. If the account is sent to an attorney or collection agency for collection purposes, I agree to pay collection expenses and reasonable attorney fees as established by the court and not by a jury in any court action.
• I understand and agree that if my account is delinquent, I may be charged interest as the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to EyeSight Medical Center. If my insurance company or health plan designates co-payments and/or deductibles, I agree to pay them. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of the bill.
Disclosure of PHI:
• I consent to the use or disclosure of my Protected Health Information (PHI) by EyeSight Medical Center for the purposes of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of EyeSight Medical Center.
• I understand I have the right to request restrictions as to how my PHI is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. EyeSight Medical Center is not required to agree to the restrictions that I may request. I have the right to revoke this consent, in writing, at any time, except to the extent that EyeSight Medical Center has taken action in reliance on this consent.
• My "Protected Health Information (PHI)" means health information, including demographic information, collected from me and created or received by EyeSight Medical Center, another healthcare provider, a healthcare plan, my employer or a healthcare clearinghouse. This PHI relates to my past, present, or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.
• I understand I have the right to review EyeSight Medical Center's Notice of Privacy Practices prior to signing this document. The EyeSight Medical Center's Notice of Privacy Practices are posted in an accessible area in the office and have been provided to me in writing. The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that may occur in my treatment, payment of my bills, or in the performance of health care operations at EyeSight Medical Center. This Notice of Privacy Practices also describes my rights and EyeSight Medical Center's duties with respect to my PHI.
EyeSight Medical Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy to be sent in the mail, or asking for one at the time of my next appointment.