Instructions:

Please complete all of the tabs before submitting.  Please provide as much information as you can for both the Medical Insurance and Vision Plan, if applicable, in order for us to call for your benefit information prior to your visit.  Please bring your insurance cards with you to your appointment.  Thank you and we look forward to your visit.


Demographics
  Title First Last MI Suffix Nickname
Name:
Address (Line 1):
Address (Line 2):
City: State: Zip:
Home Phone: Work Phone:
Cell Phone: Email:
SSN: Occupation:
Birthday Sex: Male Female
Marital Status:
Employment Status: Employed Full-Time Student Part-Time Student
Employer/School Name:
Misc/Guardian

If Someone Else is Responsible for Your Account:

Only fill out below if someone else is responsible (mom, dad, spouse, etc.)

Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address
CityStateZipCode
Home Phone:
Work Phone:

The complete list of insurances we accept is listed on our insurance page. If your carrier is not listed in the drop down boxes below, we would be considered an "out of network" provider and you would need to submit to your carrier for reimbursement. Please contact us or your insurance carrier if you have any questions.

Vision Plan
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
SSN:
Employer/School:
Primary Medical Plan
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical Plan
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Supplemental Plan
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Medical History

Please answer the questions below. We realize that some may be more ocular relevant than others, but we are now being required to ask them to satisfy new insurance regulations. Thank You.

To set all of the following answers to 'None' click here.


Ft: In:
Type: How Long:
Type: Amount/week:
Have you had a Recent Flu Immunization?

If you are Diabetic, what was your last Glucose Reading?
When was it taken?
What was your last HA1C?
When was it taken?

Previous Care
Name of Previous Eye Doctor: Date Last Seen:
Name of Primary Care Physcian: Last Visit:
Reason for last visit to Primary Care Physcian:

Contact Lens Wearers
Current Brand:
How old is your current pair?
What is your replacement schedule?
Solution Used:
Submit Data
* I have read and understand the HIPAA Acknowledge Receipt & Consent Statement.

Ganly Vision Care, PC

HIPPA Acknowledge Receipt & Consent

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices that has been made available to you describes these uses and disclosures in more detail. You are free to refer to this Notice at any time before you sign this form and it is also available on our website for your review. As described in this Notice, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information, as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Even though an insurance plan may be in effect insuring you for services rendered by our office, a final determination of benefits can only be made after a claim has been processed. As a courtesy to you, Ganly Vision Care is hereby authorized to submit a claim to your insurance carrier (assuming we participate in your plan); however, you agree to be responsible for any fees left unpaid by the carrier. In the event that an account requires settlement through an outside collection agency, you will be responsible for all costs associated with the collection of the account, including legal fees, if any.

When you accept this document, you signify that you agree that we can, and will, use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have been offered a copy of our Notice of Privacy Practices.

You have the right to request us to restrict the use and discloser of your information, but as described in our Notice of Privacy Practices, we are not required by law to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us and we will make every effort to honor all reasonable requests. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that the Notice of Privacy Practices from Ganly Vision Care has been made available to me.


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Notice of Privacy Practices

Ganly Vision Care, PC
402 Bayard Road, Suite 200
Kennett Square, PA 19348
484-770-8132

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR INFORMATION IS IMPORTANT TO US.


General Rule

We respect our legal obligation to keep health information, which identifies you, private. The law obligates us to give you notice of our privacy practices which is effective April 14, 2003.

Generally, without your written permission, we can only use your health information in our office, or disclose it outside of our office, for purposes of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.

Uses or Disclosures of Health Information

Examples of how we use information for treatment purposes:

  • When we set up an appointment for you.
  • When our technician or doctor tests your eyes.
  • When the doctor prescribes glasses or contact lenses.
  • When the doctor prescribes medication.
  • When our staff helps you select and order glasses or contact lenses.
  • When we show you low vision aids.

We may disclose your health information outside of our office for treatment purposes, for example:

  • If we refer you to another doctor or clinic for eye care or low vision aids or services.
  • If we send a prescription for glasses or contacts to another professional to be filled.
  • When we provide a prescription for medication to a pharmacist.
  • When we phone to let you know that your contact lenses are ready to be picked up.

Sometimes we may ask for copies of your health information from another professional that you may have seen before.

We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:

  • When our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services.
  • When we prepare bills to send to you or your health or vision care plan.
  • When we process payment by credit card and when we try to collect unpaid amounts due.
  • When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan.
  • When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.

We use and disclose your health information for healthcare operations in a number of ways. Health care operations mean those administrative and managerial functions that we have to do in order to run our office. We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, and for outside storage of our records.

Appointment Reminders

We may call you, leave voicemail messages or send mailers to remind you of scheduled appointments. We may also notify you of other treatments, services or products that are available at our office that might be of help to you.

Uses & Disclosures without an Authorization

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never happen at our office at all. Such uses or disclosures are:

  • A state or federal law that mandates certain health information be reported for a specific purpose.
  • Public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the 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, audits by Medicare or Medicaid, or investigation of possible violations of healthcare 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.
  • Uses or disclosures for health related research.
  • Uses and disclosures to prevent a serious threat to health or safety.
  • Disclosures relating to workers' compensation programs.
  • Disclosures to business associates who perform healthcare operations for us and who agree to keep your health information private.

Other Disclosures

We will not make any other uses or disclosures of your health information unless you sign a written authorization form. You may revoke this authorization at any time; unless we have already acted in reliance upon it.

Your Rights Regarding Your Health Information

The law gives you many rights regarding your health information.

  • You can ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or healthcare operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to our office at the address shown at the beginning of this notice.
  • You can ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to Dr. Ken Ganly at the address shown at the beginning of this notice.
  • You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. Primarily, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally required. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we sent you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to our office at the address shown at the beginning of this notice.
  • You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to Dr Ken Ganly at the address shown at the beginning of this notice.
  • You can get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. In the event of a purchase or merger, the records will remain with the practice. If you want your records transferred, we will do so with written authorization.

Our Notice of Privacy Practices

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with, and as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and will post it on our website.

Complaints

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to Dr Ken Ganly at the address shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

For More Information

If you want more information about our privacy practices, please contact us at the address or phone number shown at the beginning of this notice.


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Existing Patients

If you have moved or any of your patient information has changed please contact
our office at 484-770-8132.
We will generate a pass code allowing you to verify and update your patient information.


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