We are committed to providing you with the best possible medical and vision care. If you have special financial needs, we are willing to work with you . The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services. We will file your insurance as a courtesy to you, however you are ultimately responsible for your bill. There is a restocking fee of a % of the total purchase fee, for each purchase. The office has the right to waive that at their discretion. THERE IS A $25.00 no show appointment fee, that fee will apply to canceled appointments with out a 24 hr notice.
1. Our office participates with a variety of insurance plans including Medicare. It is your responsibility to: Have your insurance card that is current and active at every visit. Pay your copayments and or your deductibles at the time of service. Payment can be made by cash, check or credit card. We accept Visa, Master Card, American Express, and Discover. Pay in full for any medical care or services that are not covered by your insurance plan.
2. If you have insurance that we do not participate in, our office is happy to file a claim upon your request, however payment in full is expected at the time of service.(Any and all over payments will be refunded if the insurance pays out to our office.)
3. Referral for HMI, POS, Medicaid, Peachcare: Is YOUR responsibility to any required referral for treatment at or prior to the visit. If you do not have a referral, your visit may be rescheduled or you will be financially responsible for the visit.
4. If the patient is a minor (18 years or younger and not emancipated) The parent or guardian must sign below. The parent or guardian who presents with the minor is responsible for any payment due at the time of services or any remaining balance after the insurance pays and bringing an insurance card to every visit along with any and all referrals.
5. If you have any questions about your insurance, we are happy to help you . However specific coverage issues should be directed to your insurance company member services department. The telephone number will be located on your card. If you give us incorrect insurance information and we have to refile your claim to receive payment you will be charged a re- submission fee. $25.00.
6. If you fail to make payment in full for services rendered to you, your outstanding balance will be sent to an outside collections agency . You will be responsible for any fees associated with the collection of your outstanding balance. Late fees will be added on any balance (Insurance or patient) over 90 days old. A statement of fees will be added to billing for services that were due at the time of the visit.
Consent for Use or Disclosure of Protected Health Information For Payment, Treatment, and Healthcare Operations
By signing below, you hereby consent for Optic Owl CO Fukuzato Eye Care to use or disclose information about yourself (or another person for whom you have the authority to sign for) that is protected under the federal law , for the sole purpose of treatment, payment, and health care operations. You may refuse to sign this consent form. If that is your choice we will allow you to pay in full cash for all services and supplies rendered before the exam begins and other materials are rendered.
If you want to read the NOTICE OF PRIVACY PRACTICES for the PHI before signing the consent, please ask for a copy. The terms of the notice may change from time to time, and you may always get a revised copy of this by asking the Privacy Office for Optic Owl Co/Fukuzato Eyecare. You have the right to request that Optic Owl / Fukuzato Eyecare restrict how PHI is used or disclosed to carry out treatment, payment, or health care operations.
Optic Owl Co Fukuzato Eyecare agrees to your request for restrictions, as the restrictions are binding on this. Information about you is protected under federal law, and you have the right to revoke the consent, unless we have taken action in reliance on your authorization (as determined by our privacy office). By signing below, you recognize that the protected health information used or disclosed pursuant to this consent may be subject to re-disclosure with the recipient and may no longer be protected under federal law.
Access Inspect and Copy:You have the right to review or get copies of your PHI , with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicable do so.You must make a request in writing to obtain access to your protected PHI. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address listed below. Notice if you prefer we will prepare a summary or an explanation of your PHI for a fee. $25.00 We may deny your request to inspect and copy your PHI in certain limited circumstances . If you are denied access to your information, you may request that the denial be reviewed. A licensed healthcare professional chosen by us will review your request and the denial. The person performing this review will not eb the same one who denied your initial request. Under certain conditions our denial will not be reviewable. If this event occurred we will inform you in our denial letter that the decision is not reviewable. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes other than treatment, payment, health care operations, where you have provided an authorization and certain other activities, the last 6 years. If you request this accounting more than once in a 12 month period , we will charge you a reasonable cost based fee for responding to the additional requests. Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your protected PHI. Any agreement we may make a request for additional restrictions must be in writing signed by a person authorized to make these agreements on your behalf. You may terminate this restriction if you submit the termination in writing or if we inform you that we are terminating the restriction. Any termination will apply only to PHI created or received after receipt of the termination. In your written request tell us: (10 Information whose disclosure you want to limit, (2) how you want to limit our use and or disclosure of the information. In the event that the products or services were paid out of pocket in full at your request, we will not share information about those services with a health plan or for purposes of payment or health care operations. “Health plan” means an organization that pays for your medical care. Alternative communication: You have the right to request in writing that we communicate with you about your PHIby alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Although you may initiate your request verbally, you must make your request in writing. We must reasonably honor your request. However, the request must allow us to communicate and serve you effectively. Amendments: You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If you disagree with our decision, you may submit your written statement of disagreement to be appealed to the information you wanted amended. If we accept your request to amend the information, we will make a reasonable effort to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. Electronic Notice: If you receive this notice on our website or by electronic mail (email), you are entitled to receive this notice in written paper form. Questions and Complaints: If you want more information about your PHI and or our privacy practices please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with the decision we made about access to your PHI or in response to a request you made to amend or restrict the use of disclosure of your protected health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S . Department of Health and Human Resources upon request written only. We support your right to the privacy of your protected health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Signature of Understanding: I have read the above stated financial policy, I accept the responsibility for services as outlined above.
