Please bring all insurance cards with you to your appointment.

It is customary to pay for professional services when rendered. Checks: Dishonored checks will be electronically debited from your account for the check amount plus a processing fee of $25.00.

Our office charges $30.00 for missed appointments and appointments cancelled without 24 hours notice. This fee is not billable to insurance.

I am an adult 18 years of age or older, or am the parent/guardian of the minor child whose name appears below and hereby authorize ADVANTAGE VISION CENTER to perform such eye care and treatment on me or my minor child as it deems appropriate and consent to such care and treatment, I further authorize my child to order and purchase goods and services and agree to pay for them whether performed on me or my child.

I hereby assign payment of authorized insurance (Medicare, Medicaid or any other third-party payor) to which I am entitled to be made to ADVANTAGE VISION CENTER for any goods or services furnished. I also authorize ADVANTAGE VISION CENTER to release medical information to my insurance company(ies) now or in the future for claim consideration purposes. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that the filing of a claim for any services rendered does not guarantee payment from my insurance company. I fully understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

Our staff will assist you in dealing with your insurance company by verifying your benefits using the member services phone number given on your insurance card; however, this verification is not a guarantee of payment, and it is your responsibility to know and understand your own insurance benefits, coverage and authorization requirements, Additionally, all amounts owed by patients under contracted insurance plans (co-pays, deductibles, and non-covered services) are payable at the time of service. Any service that is rendered by this office, which is not a covered benefit under your insurance policy, is your responsibility to pay. In order to process your insurance claim you must present your insurance card or voucher at the time of service. Failure to do so may result in denial of your claim.

A Dilated Fundus Exam is recommended during your vision examination. Dilation allows the Doctor a better view of your retina. This allows the Doctor to screen for problems that can occur due to systemic diseases such as diabetes and hypertension, along with eye issues such as glaucoma macular degeneration, and cataracts. Dilation can blur your vision and make you sensitive to lights. Pupil size generally begins to reduce in about two hours. Any lasting effects such as redness and swelling or ocular pain should be reported as soon as possible. Dilation may also assist in determining the final glasses prescription, especially in young children. The benefits of the OPTOMAP Retinal Screening include an in depth digital view of nearly the entire retina and it provides a permanent record to compare and track potential eye diseases.

I understand that as part of my health care, ADVANTAGE VISION CENTER originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

• The privacy of your health information is important to us.
• We maintain physical, electronic, and procedural safeguards that comply with federal regulations to protect your health information.
• We do not share your health information unless permitted or required by law for treatment, payment, or health care operations, or unless you authorize it.

• The right to review the notice prior to signing this consent.
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that ADVANTAGE VISION CENTER is not required to agree to the additional restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I wish to have the following restrictions to the use or disclosure of my health information:

I understand and have been provided with an opportunity to review the Notice of Privacy Policies that provide a more complete description of information uses and disclosures.

Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about the Privacy Ruler, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) along with a brief overview of our Notice of Privacy. We are complying with the HIPPA’s regulations.

When the Health Insurance Portability and Accountability Act (HIPPA) was passed in August 1996 this gave the federal government the ability to mandate how healthcare plans, providers and agencies send a patient’s personal information as it relates to healthcare. The Privacy Rule was created to protect your rights as a patient of our practice and we are required by law to be compliant with this regulation on April 14, 2003. Under this rule you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to take action if your privacy is compromised by following the practice’s policy. Our practice is dedicated to maintaining the privacy of your personal information.

Any health information you provide our practice, including your mailing address. Information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment and/or that identifies you as an individual.

Our practice has an official Notice of Privacy Practice (NPP) posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice Privacy Practices at any time. It will be posted in our waiting room and you can ask for a copy of the current notice at any time.

Treatment Payment Appointment Reminders Release of Information to Referring Sources * Treatment Options Disclosures Required by Law Health Care Operations * Health Related Benefits and Services Hearing Aid Companies

Public Health Risks * Health Oversight Activities * Lawsuits and Similar Proceedings * Law Enforcement * Deceased Patients * Workers Compensation * Serious Threats to Health and Safety Research * Military National security * Inmates * Organ and Tissue Donation

You have rights regarding the IIHI that we maintain about you. In our Notice of Privacy you can view the policies and procedures you will need to follow for the areas listed below.
1. Confidential Communications
2. Requesting Restrictions
3. Inspection and Copies
4. Amendment
5. Accounting of Disclosures
6. Right to a Paper Copy of this Notice
7. Right to File a Complaint
8. Right to Provide an Authorization for Other Uses and Disclosures

If you have any questions regarding this notice or our health information privacy policies, please contact:
Advantage Vision Center's Compliance Officer
1016 South Church Street, Charlotte, NC 28203-4002
appts@advantagevisioncenter.com • (704) 375-3935