Your signature below forms a binding agreement between Optometric Physicians of Middle Tennessee (the provider of services) and the Patient who is receiving services, or the Responsible Party (when applicable). Responsible Party is the individual who is financially responsible for payment of bills.

For patients without insurance benefits, payment is due in full at time of service. For patients with insurance benefits, the estimated patient responsibility is due in full at the time of service.

The Patient or the Responsible Party must:

• Inform Optometric Physicians of Middle Tennessee of the current address and phone number for the patient and the Responsible Party.

• Present all current insurance cards prior to each office visit.

• Contact medical and/or vision insurance company to confirm coverage.

• Verify at each visit that the information is current.

• Pay any required copay or portion insurance will not cover at time of visit.

• Pay any balance due in full within 30 days of receiving a statement from our office. *Partial payments will not be accepted. 

PAYMENT ARRANGEMENTS: For your convenience we accept all major credit cards, cash and checks drawn from local banks. We do not accept postdated checks. Extended payment plans are available through corporate financing (CareCredit) and we can easily assist you with the application process, which must be completed and approved prior to the actual procedure.

RETURNED CHECK POLICY: If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), or Account Closed (AC), the Patient or Patient’s Responsible Party will be responsible for the original check amount in addition to a $30.00 Service Charge. Once notified by our office, if payment in full is not made within 15 days by the Patient or Responsible Party, the account may be turned over to our collection agency. 

REFUND POLICY: Optometric Physicians of Middle Tennessee has a NO refund policy--all sales are final.  Instead, we will work to ensure that you are satisfied with your purchase.

COLLECTION FEES AND EXPENSES: You understand and acknowledge that you are responsible for any fees or expenses, including reasonable attorney’s fees and collection agency fees incurred by Optometric Physicians of Middle Tennessee  in collecting any balances due under the terms of this Agreement. Fees will be in addition to the balance due.

By signing below, you agree to accept FULL FINANCIAL RESPONSIBILITY as a patient who is receiving services or as the parent/guardian for the patient. You authorize payment of benefits to Optometric Physicians of Middle Tennessee. Your signature verifies that you have read the above, had the opportunity to ask and have answered any questions, understand your responsibilities, and agree to these terms.

 RETINAL SCAN

As part of a comprehensive eye examination, it is recommended that ALL patients have the internal health of their eyes thoroughly evaluated every year.  This is performed as either a dilated retinal examination or the retinal imaging.

Our practice is pleased to provide all of our patients with the most highly advanced technology available in retinal imaging today!  Our ability to view your internal retinal health is now dramatically improved with digital retinal imaging.

Your doctor is concerned about uncovering and documenting problems such as macular degeneration, glaucoma, retinal holes or detachments, and diabetic retinopathy (all of which can lead to partial loss of vision or blindness).  Systemic diseases such as diabetes and high blood pressure can also be discovered during a retinal examination.  

These health conditions are difficult to detect without the Digital Retinal Examination or Dilation of the pupils with eye drops due to the limited view of the internal structures of the eye.

Digital Retinal Scan:

Provides an eye wellness scan

Gives in depth view of the retinal layers (where disease can start)

Allows your doctor to review your digital retinal image with you

Provides an annual, permanent record for your medical file

Is fast, easy, and comfortable

Will NOT require dilating drops, which result in blurred vision and sensitivity to light for 4-6 hours.  Some patients may need to have their eyes dilated also.

PLEASE NOTE:  THERE IS AN ADDITIONAL CHARGE OF $43 FOR THE 

DIGITAL RETINAL EXAM WHICH IS NOT COVERED BY INSURANCE

Your Information. Your Rights. Our Responsibilities.
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.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.  We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on this form.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting:
We will not retaliate against you for filing a complaint.
Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

Our Uses and Disclosures

How do we typically use or share your health information?
We typically use or share your health information in the following ways:

Treat you
We can use your health information and share it with other professionals treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues
We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.

Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.