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