PLEASE READ 

 

Periman Eye Institute, PLLC is not contracted with any insurance plans, this includes Medicare, Medicaid, Medicare replacement/supplement plans and all commercial plans. We do not file any insurance claims or accept payments from insurance. This means that payment is due at the time of the services. Superbills can be generated upon request for self submission to your insurance along with chart notes and codes. Check your policy to see if self submission of claims is allowed. Plan reimbursment is variable and typically less than the fair market value. An important exemption to this is patients with Medicare, Medicaid, Medicare replacement/supplement plans. Patients covered by Medicare will receive a Medicare Private Contract as is required in compliance with Medicare's Opt Out provider guidelines.

 

Although we do not except insurance for our services, any prescriptions we prescribe may be covered by your insurance. Our team is committed to assisting with any prior authorizations from your plan. Please provide your insurance for assistance with prescriptions. 

Thank you for choosing Periman Eye Institute, PLLC. We are committed to building a successful physician- patient relationship with you. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Your payment for services is a part of that relationship.

Please ask if you have any questions about our fees, our policies or your responsibilities.

It is your responsibility to notify the office of any patient information changes (i.e. address, etc

Fees are due at the time of service and professional fees are non-refundable.

Periman Eye Institute, PLLC does not file any insurance claims, this includes Medicare, Medicare replacement/supplement plans, Medicaid and commercial insurance.

For all patients who are covered by a Medicare plan, a Medicare Private Contract will be emailed to you for signature and is required in compliance with Medicare's Opt Out Provider guidelines.

All patients are required to establish care with Dr Periman via an initial virtual visit prior to scheduling any in person appointments. 

Consultation rates with Dr Periman vary from $275 - $500 depending on time and complexity.

Additional charges that may be incurred with consultations include diagnostic testing ($75/each), and diagnostic imaging ($175).

We offer a variety of dry eye treatments including IPL, iLUX, Epionce Chemical Peels, Triple MCH, Maskin Probing and ZEST just to name a few.

Please feel free to inquire about any prices and/or procedures.

Cancellations: If you need to cancel your appointment, please email concierge@perimaneyeinsitute.com at least 24 hours prior to your scheduled appointment. Short notice cancellations (less than 24hours) will be charges a cancellation fee. If habitual short notice cancellations become an issue, pre-payment will be required to reschedule.

My signature below acknowledges that I have read and understand the above Financial Policy. I fully accept responsibility for all payments due at the time of service.

Consent for Medical Photography

I consent for medical imaging (photo, video, and/or audio) to be made of me. I understand that the information may be used in my medical record, for purposes of medical teaching by Laura M. Periman, MD and fellows, or for publication in medical textbooks or journals as I have designated below. By consenting to medical photography I understand that I will not receive compensation from any party. Refusal to consent to photographs, video, and/or audio recording will in no way affect the medical care I receive. If I wish to change or withdraw my consent in the future, I will notify the staff at Periman Eye Institute, PLLC via email to: concierge@perimaneyeinstitute.com

 

By signing below, I indicate that I have read and understand the Telehealth and Medical Photography Policy

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

Personally identifiable information about your health, your health care and your payment for healthcare is called Protected Health Information (PHI). We must safeguard your PHI and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in the situations ser out in the Notice, we must use or disclose only the minimum necessary PHI to carry out the use.

We must follow the practices describes in this Notice, but we may change our privacy practices and terms of this Notice at any time. If we revise the Notice, you may read the updated version of the Notice of Privacy Practices on our website at dryeyemaster.com

You may request a copy of the Notice of Privacy Practices by calling 206-347-0821. A copy of the Notice will be mailed to your home address. You may also request a copy at your appointment.

Uses and disclosures of your PHI that do not require your consent: We may use and disclose your PHI as follows without your permission: *For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care. For example, your information may be shared with the person performing your lab work or specialty pharmacy assisting with prior authorization. *To obtain payment. We may disclose your health information in order to collect payment for services

*For health care operations. We may use or disclose your health information in order to perform business functions like employee evaluations and improving the services we provide. We may disclose your information to students training with us. We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when the doctor is ready to see you. *When required by law. We may be required to disclose your PHI to law enforcement officers, courts or government agencies. *For public health activities. We may be required to report your health information to government agencies to prevent or control disease or injury. We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety. *For health oversight activities. We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses. *For activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they may carry out duties related to your death, such as determining the cause of death or preparing your body for burial. We also may disclose your information to those involved with locating, storing and transplanting donor organs or tissue. *For studies. In order to serve our patient community, we may use or disclose your health information for research studies, but only after that use is approved by a special privacy board. In most cases, your information will be used for studies only with your permission. *To avert a threat or health safety. In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen the threat.

*For specific government functions. In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs and for national security

*For workers' compensation purposes. We may disclose your health information to government authorities under workers' compensation laws.

Uses and Disclosures of Your Protected Health Information that Require Your Consent The following uses and disclosures of your PHI will be made only with your written permission, which you may withdraw at any time: *For research purposes. In order to serve our patient community, we may want to use your health information in research studies. For example, researchers may want to see whether your treatment improved your condition. In such instances, we will ask you to complete a form allowing us to use or disclose your information for research purposes. Completion of this form is completely voluntary and will have no effect on

*For marketing purposes. Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment. Additionally, without your permission we will not sell or otherwise disclose your PHI to any person or company seeking to market its products or services to you. *For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.

Your Rights Regarding your Protected Health Information (PHI) You have the following rights related to your PHI: *To inspect and request a copy of your PHI. You may look at and obtain a copy of your PHI in most cases. You may not view or copy information collected for use in a legal or government action and information which you cannot access by law. *To request that we correct your PHI. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file. We may deny your request if we find that the information is correct and complete, not created by us, or not allowed to be disclosed. If we deny your request, we will explain our reason for the denial and your rights to have the request, denial and written reason for the denial added to your file. If we approve the request, we will change the information, report the change to you and to others that need to know about the change in information. *To request a restriction on the use or disclosure of your PHI. You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request. If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations. We cannot limit uses or disclosures that are required by law. *To request confidential communication methods. You may ask that we contact you are a certain address or in a certain way. We must agree to your request as long as it is reasonably easy for us to do so. *To find out what disclosures have been made. You may get a list describing when, to whom, why and what of your PHI has been disclosed during the past six years. We must respond to your request within sixty days of receiving it. We will only charge you for the list if you request more than one list per year. The list will not include disclosures made to you or for purposes of treatment, payment and health care operations. *To receive notice if your records have been breached. Periman Eye Institute, PLLC will notify you if there has been an acquisition, access, use or disclosure of your PHI in a manner not allowed under the law and which we are required by law to report to you. We will review any suspected breach to determine an appropriate response under the circumstances. *To obtain a paper copy of this Notice. Upon request, we will provide you with a printed copy of this Notice.

How to File a Complaint about our Privacy Practices. If you feel we may have violated your privacy rights, or if you disagree with a decision we made about your PHI, you may file a written complaint with our Privacy Officer, AnaLucia Clarkson. (Mail: 100 W. Harrison, North Tower, Suite 360, Seattle, WA 98119. Fax: 206-580-4003 You may also file a complaint with the Secretary of the US Department of Health and Human Services by writing to: 200 Independence Avenue SW, Washington, DC, 20201 or by calling 1-877-696-6775. We will take NO action against you if you file a complaint to either or both of these persons.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to PHI. If you have any questions regarding this Notice or about our privacy

practices, please contact our Privacy Officer, AnaLucia Clarkson. (analucia@perimaneyeinstitute.com)

My signature acknowledges I have read and understand the privacy practices detailed in this Notice.

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