If your insurance is not listed above, we would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.

1. It is important for patients to be informed consumers who understand the specifications of their insurance policies. Your health insurance policy is a contract between you and the insurance company.

2. Each individual patient is responsible for all payment obligations arising out of treatment and care guarantees payment for these services. You are responsible for deductibles, co-payments, co-insurance, or any other patient responsibility indicated by your insurance carrier.

3. Our office may check eligibility, however, you will be held responsible for knowing the extent and specific insurance policy. Please note that some insurance companies contract with third-party carriers for routine vision coverage and Dr. Green may not be contracted with those vision carriers. Always verify with your insurance company that Dr. Green is a preferred provider in order to get the best benefits possible.

4. Your insurance company makes a final determination of benefits when they receive our billings. Any statements made by our staff regarding your coverage are made in good faith but may not be completely accurate even if we have your insurance information to verify your coverage.

5. If there are any problems between you and your insurance company, you may file a grievance directly with your insurance company.

6. If payment has not been received within 4 months on an outstanding balance, the account may be sent to a third-party collection agency.NSF checks or rejected credit card payments will be charged a service fee of $30.00 per occurrence.

7. Please feel free to ask any financial questions you may have. Again, our intent is to provide you with the highest level of service and care.

By signing below, I acknowledge that I understand the policies as contained herein.

Do you or your immediate family (parents/siblings/children) have any of the following conditions?

(Checked box indicates YES, blank boxes indicate NO)

THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY. Your "health information," for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as "health information" in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also include consent to such payment.

Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so.

Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

Contact Person:

Complaints:

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown above. If you prefer, you can discuss your complaint in person or by phone.

We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.

I acknowledge that I received a copy of Bellingham Family Eye Clinic, Notice of Privacy Practices, dated August 31, 2013. I may request a copy if I desire one for my own records.