Acknowledgement Of Receipt For HIPAA Compliancy

I have received a copy and/or read the Health Insurance Portability and Accountability Act. This Act protects the privacy of your medical
information.

About Your Insurance

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts
both.
• Vision Care Plans. (Such as Eyemed and VSP)
• Medical Insurance. (Such as Blue Cross/Blue Shield and Medicare.)
• Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening
   for eye disease. They do not cover diagnosis, management or treatment of eye diseases.
• Medical insurance must be used if you have any eye health problems or systemic health problem that has ocular complications. Your
   doctor will determine if these conditions apply to you but some are determined by your case history.
• If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We
   will use coordination benefits to do this properly and to minimize your out of pocket expense.
• We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization
   of your insurance benefits so we can tell you what is covered of some fees are not paid by your plan, co-pays or non-covered services as
   allowed by the insurance contract.
• If your medical insurance denies claim submitted by the office you will not be responsible for that portion of the services. Any and all
   copay’s through vision insurance or for a routine vision exam are the responsibility of the patient.
 

I have read and agree with these policies.

Please read the INSURANCE BILLING information carefully. If you have any questions, please let us know before you are seen for your
appointment. Our office policy requires that we no longer refile, reverse, or back date claims on either medical or vision insurance. Also, please
note that any EOBs [explanation of benefits] from your insurance company are for information purposes only and NOT a bill from Vision Plaza,
PA

Vision Insurance generally provides you with substantial discounts on routine vision requirements, such as visual acuity testing and
prescription eyeglasses; it is a wellness benefit. In contrast, medical insurance usually covers the diagnosis and professional management
of ocular disease, as well as other emergency eye complications. This includes comprehensive eye exams, dilation and treatment for
conditions such as macular degeneration, glaucoma and diabetic retinopathy. When you make a claim to your medical insurance that is
based on our eye doctor’s diagnosis of a health condition, it will typically be approved.