THE OPTOMETRY CENTER FOR VISION THERAPY

Though OCVT takes every possible step to ensure our communications are as secure as possible, communications via email cannot be guaranteed to be secure. Although it is highly unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties aside from the person to whom it is addressed.
IF YOU WISH FOR OCVT TO USE EMAIL COMMUNICATION VIA THE EMAIL ADDRESSES LISTED ABOVE, PLEASE INDICATE YOUR CONSENT:

I DO CONSENT for OCVT to communicate with me via email:

AUTHORIZATION TO DISCLOSE CONFIDENTIAL HEALTHCARE INFORMATION
Federal law states that if a patient is 18 years of age or older, our practice may not share the patient’s healthcare information with any parties (including parents and/or caregivers) without express permission from the patient or patient’s guardian. Your signature below indicates you are providing our clinic with permission to share the patient’s healthcare information with the individuals you list below. This authorization is voluntary and can be revoked at any time by providing a written revocation to the Patient Services Team. This authorization will be in effect until any revocation is received. This authorization does not allow for listed parties to make healthcare decisions for the patient, but only to have access to healthcare information. There is another section of the form to enter your request to release private health information to other professionals. Please use this section to name any non-guardian caregivers or family members you would like to have access to this patient’s information.

PLEASE CAREFULLY READ THE ACKNOWLEDGEMENTS BELOW AND INDICATE YOUR CONSENT

I hereby acknowledge that this clinic’s Notice of Privacy Practices are available upon request at any time. Please reach out to a Patient Services Coordinator if you would like to request a copy and we’d be happy to assist.

I hereby consent for the patient to be treated by this clinic. I authorize this clinic to exchange pertinent information (including copies) found within the patient’s records as needed to care for the patient, and for the following purposes: for optimal treatment, to facilitate payment and healthcare operations, and to provide applicable healthcare procedures by the doctors and staff of the clinic (which may include diagnostic/treatment procedures). I authorize permission to send medical records to referring provider or other providers collaborating in the care of the patient.

The Health Insurance Portability and Accountability Act (HIPAA) states that if a provider is not contracted with an insurance company, the clinic may not release any of the patient’s protected healthcare information. I hereby acknowledge that I am aware that a written release is required if any communication is needed between the clinic and the patient’s insurance company.

This appointment is a no-cost vision and eye health exam that is offered as a part of the InfantSEE program. Though this appointment is no cost, we want to ensure you are aware of our financial policy in the event that future appointments are recommended for the patient. I hereby acknowledge that I am aware of the clinic’s financial policy.
FINANCIAL POLICY: This clinic is a private pay practice and does not file claims with any insurance companies. It is the patient or parent/guardian’s responsibility to determine how to submit information, file claims, or determine coverage.
Payments must be made at the time services are rendered. I understand that if my account ever incurs a balance due that is not paid immediately, the account may be sent to collections, and a fee of up to 25% of the balance due will be added.

The InfantSee program is a public health program designed to encourage eye health from the start of an infant’s development. Please see www.infantsee.org for more information. As part of the program, we are required to submit data from each exam with no patient identifying information for statistical purposes. I understand and consent to my child’s information will be submitted to the database confidentially and without identifying information.

By signing below, I consent to the above listed providers receiving updates and reports from OCVT for collaboration on my care, including calls, record sharing, and school observations as applicable.

My signature below authorizes this clinic to share any of the patient’s medical records via phone or electronically, and to schedule school observations as the provider deems necessary. I understand that I may revoke this authorization at any time except for actions already taken based upon it. I understand that to revoke this authorization, I must submit a written revocation to the Patient Services Team via fax, mail, or in-person. I understand that this release does not expire unless or until a written revocation is received. I understand I may request a copy of this document at any time.

My signature below certifies that the information provided in this form is accurate to the best of my knowledge.

I hereby authorize The Optometry Center for Vision Therapy to share medical information of the patient named above.

I understand that:

• I may revoke this authorization in writing at any time, except for any actions already taken based upon it.
  To revoke this request, please submit the revocation in writing to either OCVT address listed above via fax, mail, or in person.
• I understand this authorization will not expire until a written revocation is received from the above-listed
  patient.
• I may request a copy of this form after it is signed.

The Optometry Center for Vision Therapy is a private pay practice. This means we do not accept insurance of any kind, and you are responsible for payment in full at the time the service is rendered. You are responsible for filing a claim with your insurance company for services rendered, if you choose to do so. Treatments may be covered under major medical insurance, but we cannot guarantee coverage. The amount of coverage you receive, IF ANY, will depend on your specific insurance policy. We encourage you to seek coverage reimbursement from your insurance company. Under all forms of major medical insurance, you have the right to request a review of any service that is denied coverage or for which coverage is limited. If you believe that your plan has incorrectly evaluated the claim for coverage, acted arbitrarily, or discriminated unfairly against you, we encourage you to request a review.