I hereby acknowledge and agree to accept the policies stated above.
I have the right to review the Notice of Privacy Practices prior to signing this consent. EyeCare Professionals, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to EyeCare Professionals, P.A.'s Privacy Officeer at 1501 Lakeland Drive, Suite 100, Jackson Mississippi 39216.
With my consent, EyeCare Professionals, P.A., may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, optical goods ordered, and any call pertaining to my clinical care, including laboratory results among others.
With my consent, EyeCare Professionals, P.A. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, and patient statements, as long as they are marked personal and confidential.
With my consent, EyeCare Professionals, P.A. may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that EyeCare Professionals, P.A. restrict how it uses or discloses my PHI to carry out TPO.
However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to EyeCare Professionals, P.A.'s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent taht the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, EyeCare Professionals, P.A. may decline to provide treatment to me.
All charges for services rendered are due and payable at the time of service.
VISION/MEDICAL INSURANCE: We have contracts with many insurance companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason.
The person signing on behalf of the Patient as the Responsible Party must:
* Inform Eyecare Professionals of the current address and phone number for the patient and the responsible party. * Present all current insurance cards prior to each office visit. * Verify at each visit that the information is current by signing our data sheet. * Pay any required copay at the time of the visit. * Pay any additional amount owing within 30 days of receiving a statement from our office. (When Eyecare Professionals receives an explanation of benefits (EOB) from your insurance company, any amounts that you need to pay will be billed to you).
Returned Check Policy If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient's Responsible Party will be responsible for the original check amount in addition to a $25.00 Service Charge. Once notice is received of the returned check, Eyecare Professionals will send out a letter to notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the patient or the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance - in addition to the $25.00 Check Service Charge.
Non-Payment on AccountShould collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient's Responsible Party, understands that Eyecare Professionals has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patient's Responsible Party, understands that they are responsible for all costs of collection including, but not limited to, interest due at 18% APR, all court costs and Attorney fees, and a collection fee will be added to the outstanding balance. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms.