- To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 14 days.
- There are certain inherent risks associated with a medical exam during a pandemic and I assume full responsibility for personal illness that may result out of my visit.
- By signing this form below, I agree that I will not hold Dr. Ashley Roth & Associates PA, or any of its doctors or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus.
- I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my exam to be essential to the maintenance of my vision.
GLASSES PRESCRIPTION & CONTACT LENS PRESCRIPTION
- My signature below confirms that I have received the hard paper original, or digital copy via email, of my spectacle and/or contact lens prescription at the completion of my exam, as is provided for by the laws and rules governed by the FTC. I am aware that I can get a copy of my prescription at any time by contacting this office and asking for a copy at no charge.
CONTACT LENS FIT & FOLLOW UP POLICY
- Contact lenses are considered medical devices and have a separate contact lens fitting fee. The fee includes 3 follow up visits within 90 days of the original contact lens exam. If 90 days have passed a follow up fee will be charged. If 6 months
have passed a new exam is required and the full exam fee will be charged.
- In accordance with Florida law, this office offers dilation at no additional cost to your examination. Dilating your eyes gives the doctor an expanded view of the inside of your eyes, and is helpful in detecting cataracts, glaucoma, retinal detachments, and other ocular disorders.
- SIDE EFFECTS: Due to the enlargement of the pupils, dilation may affect the comfort of some patients when reading or driving (usually 2 to 3 hours) and creates sensitivity to bright lights (usually 3 to 4 hours).
- I understand the risks and benefits associated with pharmacologic dilation of the pupils and have made my verbal decision to be dilated, or not to be dilated, with the doctor via informed consent.
- If you cannot be dilated today, you can return with 90 days to have dilation performed at no charge.
CONSENT FOR CONTACT VIA CALLS / TEXT MESSAGES / EMAILS
- I acknowledge and give consent that this office may call and/or send text messages and emails to me at any telephone numbers or email addresses I have provided.
AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office and is available for you to review.
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. We agree to provide patients with access to their records in accordance with state and federal laws.
7. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
24 HOUR CANCELLATION POLICY
- As of Jan 1, 2021 all patients who fail to arrive at their scheduled appointments or who cancel with less than 24 hours advance notice will be charged a missed appointment fee of $40.
- We will ask you for your credit card information in order to secure your appointment.
- Our office will make every effort to accommodate your scheduling needs. In return we ask that you help us by keeping your scheduled appointment. Due to COVID 19 we are scheduling our patients further apart and never double booking. Your appointment time is reserved solely for you. When you give us advance notice we are often able to accommodate our other patients.
- Please note that if you do not arrive to your appointment and daily to cancel with less than 24 hours advance notice you will be charged $40.
Thank you for your courtesy and understanding.
My one signature below applies to all of the consents and policies listed above. These authorizations/consents do not expire and apply to all past, present and future visits and records.