Please complete this form in its entirety;
this will better assist us in meeting your needs.
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[Person outside the home]
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I authorize Clinic for Vision, PC to release certain information from my record to the person(s) named below. I understand my record contains information about my eyes and general health from examinations, tests and consults with other doctors. There are also financial records that include information about payments and insurance. "Release of information" may include telephone or electronic communications, face-to-face conversation or electronic or paper copies of my files.
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Clinic for VIsion, P.C.
418 Martling Road, Albertville, AL 35951
We request payment in full at the time of service. We also require payment in full for glasses or contact lenses before they are ordered. Glasses not picked up within 90 days of order will be returned to the laboratory and payment forfeited.
We may accept assignment of certain insurance benefits. However, the balance remains your responsibility. We will make every effort possible to file your claim and collect your benefits, but if your insurance company does not pay, you are responsible for the bill. Any deductible and co-pay is due the day of service.
For unaccompanied minors, non-emergency treatment will be denied unless payment arrangements are made in advance. The adult who brings the minor to the office will be considered financially responsible for the child's bill.
We reserve the right to charge interest of 1.5% per month on delinquent accounts. We charge $30 for returned checks. If your account is turned over for collection, you will be billed for their service as well.
I request that payment of insurance benefits be made on my behalf to Clinic for Vision, P.C. for any services I receive. I authorize the provider to release any medical information necessary to determine my benefits. I understand that my insurer may not be able to pay my claim unless I provide sufficient information.
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NOTICE OF PRIVACY PRACTICES
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.
USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION
The most common reasons why we use or disclose your health information are for the 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 eye 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.
OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT
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:
1. When a state or federal law mandates that certain health information be reported for a specific purpose;
2. for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
3. disclosures to government authorities about victims of suspected abuse, neglect or domestic violence;
4. uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for the investigation of possible violations of health care laws;
5. disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
6. disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
7. disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
8. uses or disclosures for health related research;
9. uses and disclosures to prevent a serious threat to health or safety;
10. uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
11. disclosure of de-identified information;
12. disclosures relating to worker's compensation programs;
13. disclosures of a "limited data set" for research, public health, or health care operations;
14. incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
15. disclosures to "business associates" and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information in accordance with HIPAA;
16. [specify other uses and disclosures affected by state law].
Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for health care prior to your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.
SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosures we may not make of your health information without your authorization:
1. 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 authorization must also include consent to such payment.
2. 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.
3. 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.
YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
1. To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.
2. To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.
3. To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
4. To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information: was not created by us, unless the person that created the information is no longer available to make the amendment, is not part of the health information kept by or for us, is not part of the information you would be permitted to inspect or copy, or is accurate and complete.
5. To receive an accounting of disclosure of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically).
6. To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.
Our contacts for all questions, requests or for further information related to the privacy of your health information are: Sharon J. Carnes, Office Manager and Dr. TImothy C. Nichols
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 Service, Office for CIivil 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 email shown above. If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
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 practice 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.
Notice Revised and Effective: September 23, 2013.
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