We, at Eye Center of Atlanta, P.C., participate with many insurance plans as a convenience to our patients. However, we expect our patients to pay their share for our services, as specified in your benefits contract. We will help you determine theses amounts.

• Payment of coinsurance, deductibles, cop-pay or private pay is due at the time of service.
• Medicare Coverage: I acknowledge that I may be responsible for certain charges at the time of my visit or any related claims due to either the provisions of Medicare or lack of Medicare’s policy to cover these charges. I also understand Medicare MAY NOT pay for particular items or services. I am fully responsible for non-covered services and procedures.
• Commercial Coverage: I acknowledge that I may be responsible for certain charges at the time of my visit or any related claims due to the provisions of my insurance or insurance policy to cover these charges. I also understand my insurance MAY NOT pay for particular items or services. I am fully responsible for non-covered services and procedures.
• Private Pay: I understand payment is due in full at the time of service.
• I understand I can appeal my insurance’s payment decision

This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices. Our full length notice is posted in the reception area and a copy of the full length is available for you at the checkout desk.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY HAVE ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand that your medical information is personal to you and we are committed to protecting your information about you. As our patient, we create medical records about your health, our care for you, and the services/and or items we provide to you as our patient. By law, we are required to make sure that your information is protected and kept confidential.

• Please find some examples where we use or disclose your information (for more detail, please refer to the complete Notice of Privacy Practices)
• For medical treatment
• For emergency situations
• For Workers Compensation programs
• To obtain payment for your services
• For research
• For quality assurance
• For appointments
• Allow practice to flow efficiently
• In response to issue arising from legal matters

You, as the patient, have certain rights regarding the information we maintain about you. All requests must be made in writing, with a 48 hour notice, no exceptions. Our medical records staff/department will assist you with the written requests. These rights include:

• The right to inspect and copy your file (see rates that apply)
• The right to amend
• The right to an accounting of disclosures
• The right to a paper copy of this notice
• The right to request restrictions
• The right to request confidential communication

Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. Your have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice can change. If we change our notice, you may obtain a revised copy of this by contacting the office. You have the right to inspect that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you (or your representative) consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.