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, ad 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 YOU AUTHORIZATION
The most common reasons why we use or disclose your health information are for 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 referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of you 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 collection 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 you health information for health care operations are; financial or billing audits; internal quality assurance; personnel decision; 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:
•when a state or federal law mandates that certain health information be reported for a specific purpose;
•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;
•disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
•uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
•disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
•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;
•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;
•uses or disclosures for health-related research;
•uses and disclosures to prevent a serious threat to health or safety;
•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;
•disclosures of de-identified information;
•disclosures relating to worker’s compensation programs;
•disclosures of a "limited data set" for research, public health, or health care operations;
•incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
•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;
•[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 heath 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:
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 your authorization must also include consent to such payment.
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.
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 RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES
•Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization.
•You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose.
•We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.
•We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).
Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.
YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
•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.
•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.
•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.
•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.
•To receive an accounting of disclosures 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).
•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.
Medical History Form
General Information: Todays Date:
Patient Name ______Date of Birth______Sex M or F
How do you wish to be addressed? ______Social Security # ______
Home Address______City______State______Zip ______
Home Phone Number______Cell Number______
Occupation______Employer______Work #______
Spouse’s Name______Employer______Work #______
If a minor parents names:
Father______Employer______Work#______
Mothers Name ______Employer______Work #______
Please list any members of your household who come to our office:
______
______
I would like to discuss/ learn about: Glasses Sunglasses Contact lenses Laser Refractive Surgery
Date of last Eye Exam______Last Eye Doctor Seen______Phone #______
Name of Medical Doctor______Address______Phone #______
How did you decide to come to our practice?
Newspaper ____ Yellow Pages ____ Website ____ Facebook _____ Employer _____ Insurance website _____ Other ______
Person financially responsible for account
Name______Relationship______SS#______
Address______Phone #______Birthdate______
Insurance name ______Policy Holder______I.D. #______
Medical History
Do you have any allergies to medications? No__ Yes__ If yes, please explain:______
List or attach a separate sheet of any medications you are currently taking: ______
______
______
List all major injuries or surgeries you have had in the last 10 years: ______
______
List any of the following that you have had: Crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injuries: ______
______
Are you pregnant and or nursing? ___No ___Yes
Do you wear glasses? ___No ___Yes
Do you wear contacts? ___No ___Yes
Type of contacts: ____ Monthly ____Dailies Brand______Are they comfortable? ____No ____Yes
**** Please turn this form over and complete side two****
Family History
Please note any personal or family history (parents, siblings, children, grandparents living or deceased) for the following conditions.
Disease/Condition / Self / Family / Whom / Disease/Condition / Self / Family / WhomBlindness……………… / ___ / ___ / ______/ Diabetes………………. / ___ / ___ / ______
Cataracts……………… / ___ / ___ / ______/ Heart Disease………... / ___ / ___ / ______
Crossed Eyes………… / ___ / ___ / ______/ High Blood Pressure… / ___ / ___ / ______
Glaucoma…………….. / ___ / ___ / ______/ Kidney Disease………. / ___ / ___ / ______
Macular Degeneration.. / ___ / ___ / ______/ Lupus…………………. / ___ / ___ / ______
Retinal Detachment….. / ___ / ___ / ______/ Thyroid Disease……… / ___ / ___ / ______
Arthritis………………… / ___ / ___ / ______/ Multiple Sclerosis……. / ___ / ___ / ______
Cancer………………… / ___ / ___ / ______/ Other………………….. / ___ / ___ / ______
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
___ Yes, I would prefer to discuss my social history information directly with my doctor. (check box)
Do you drive? ___ No ___Yes If yes, do you have visual difficulty with driving? ___No ___Yes If yes, please explain:
______
Do you use tobacco products? __No __Yes If yes, type/amount/how long: ______
Do you drink alcohol? __No __Yes If yes, type/amount/how long: ______
Do you use illegal drugs? __ No __Yes If yes, type/amount/how long: ______
Have you ever been exposed to or infected with ___Gonorrhea ___Hepatitis ___HIV ___Syphilis ______Other
Review of systems
Do you currently, or have you ever had any problems in the following areas:
System Constitutional Y N ?Fever, Weight Loss/Gain
Integumentary (skin)
Neurological
Headaches
Migraines
Seizures
Eyes
Loss of Vision
Blurred Vision
Distorted Vision/ Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness/burning/itching
Sandy or Gritty Feeling
Foreign Body Sensation
Allergic/Immunologic
Psychiatirc / System Y N ?
Excess Tearing/Watering
Glare/ Light Sensitivity
Eye Pain or Soreness
Chronic Infection/ Eye/ Lid
Sties or Chalazion
Flashes/ Floaters in Vision
Tired Eyes
Endocrine
Thyroid/ Other Glandes
Ears, Nose Mouth, Throat
Allergies/ Hay Fever
Sinus Congestion
Runny Nose
Post Nasal Drip
Chronic Cough
Dry Throat / Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema / System Vascular/ Cardiovascular Y N ?
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Gastrointestinal
Constipation
Diarrhea
Genitourinary
Genitals/ Kidney/ Bladder
Bones/ Joint/ Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Lymphatic/ Hematologic
Anemia
Bleeding problems
If answered YES to any of the about or have a condition not listed please explain______
______
______
______
______
Tasha J. Jones O.D.
Jason C. Jahn O.D.
Financial Policy
Dear Patients:
Thank you for choosing us as your eye care provider. The following is our financial policy and our main concern is that you receive the proper and optimal treatments needed for your eye health. Therefore, if you have any questions or concerns about our payment policies, please do not hesitate to ask one of the office personnel.
We ask that all patients read and sign our financial policy as well as complete our Medical History form prior to seeing the doctor.
Payment for services is due at the time the services are rendered. We accept cash, checks, Visa, Mastercard, American Express, Discover and HSA cards. We will be happy to process your claim for your reimbursement, as long as you provide us with your insurance card. As a courtesy to our patients we will file the primary insurance claims and one secondary insurance claim. We request that the patient file directly with the insurance company for any additional claims.
In special instances, we may accept assignment of insurance benefits. However, you must understand that:
- Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party in the contract. Our relationship is with you, not your insurance company, we will assist you at the time of the visit.
- All charges are your responsibility whether your insurance company pays or not. Not all services are a covered benefit in all contract. Some insurance companies arbitrarily select certain services they will not cover. Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.
- If the insurance company does not pay your balance in full within 30 days, we ask that you contact the carrier to help speed things up.
- If the insurance company does not pay in full within 45 days, we may require you to pay the balance due with cash or check.
- A $5.00 service charge is added to all past due accounts. A charge of 1.5% may be assessed on all balances over 45 days.
We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems so that we can assist you in management of your account.
Than you and we appreciate your trust in us and the opportunity to serve you.
Patient
Signature______Date______