Policies/Consent
NOTICE OF PRIVACY PRACTICES
Drs. Liu and Longacre, Inc., d.b.a. Foothill Optometric Group
6155 Stoneridge Drive, Suite 100
Pleasanton, CA 94588
(925)-463-2150, Fax: (925)-463-1186
www.fogeyes.net, Email: foothilleyes@fogeyes.net
THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
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, and 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 YOUR 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 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 collecting 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 your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; 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.
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.
Contact Person:
Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Shelly Husbands, Office Manager
Foothill Optometric Group
6155 Stoneridge Drive, Suite 100
Pleasanton, CA 94588
(925)-463-2150, Fax: (925)-463-1186
Email: foothilleyes@fogeyes.net
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 the office contact person at the address, fax or E mail shown above. If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.
Notice Revised and Effective: September 16, 2013
FINANCIAL RESPONSIBILITIES AND CONSENT Financial Responsibilities
You (or your legal guardian) are responsible for the payment of your account, including payment of co-pays, coinsurance, deductibles, all other procedures or treatment not covered by his/her insurance plan and all direct or indirect fees incurred in collecting any outstanding balance.
While we will assist in filing for insurance,
we cannot guarantee coverage . As the insured, you are responsible for knowing your insurance benefits and requirements for coverage and ensuring that any necessary referrals or authorizations are obtained before receiving services. In the event of a dispute or rejection of a claim, you are responsible for payment. In order to submit a claim to insurance, we must have proof of insurance prior to your appointment. Please note you have a 30 day window from the date of service to apply any unused insurance to your order. It will be your responsibility to self submit your updated billing invoice to your Insurance Company.
We may file some types of insurance for you as a courtesy. However, you are responsible for staying in contact with the insurance company to assure that they pay in a timely manner. We may require payment for your services in full if your insurance company has not paid the benefits to us within 90 days of submission. Any insurance benefits that are later received for those services will be refunded to you. Payment is due at the time of service. We accept cash, checks, American Express, Care Credit, Discover, MasterCard and Visa.
Bring your insurance card and picture ID to each visit.
If an order for contact lenses or glasses is place by phone, a credit card number is required at the time the order is placed to pay for desired materials.
There will be a $25 fee plus our bank's fee for a returned check.
A finance charge of 1.5% per month applies to any balance over 30 days past due.
Cancelled Appointments
While we understand that there may be times when you miss an appointment due to emergencies or obligations, we ask that you give us a 24 hour notice on all cancelled appointments. We reserve the right to charge a $25 fee for all missed appointments not cancelled 24 hours prior to the scheduled appointment time.
Records Release
We will provide a report of your most recent exam results and current spectacle and contact lens prescriptions at no charge. If you request copies of your full medical records, there will be a charge of $20 (or the fee allowed by the state of California at the time of request). All charges must be paid before the records will be released.
Re-Frame Selection and Cancellation Policies
As a reminder, your glasses should be ready in about 3 weeks. If there are any delays at the lab or frame company, we will notify you to keep you informed of the status.
If it is necessary to Re-Frame Select or change lens types, we will be happy to do so within 30 days at no cost if no upgrade in either frame or lens is selected. If a frame is not in perfect condition, it cannot be returned.
If you decide to cancel your order any time after the day of the initial order, the following charges will apply:
Private-$25.00 Frame Restocking Fee, 50% Lens Fee which includes all add-ons.
Insurance-We will refund all out-of-pocket fees minus Co-payments, but insurance cannot be reinstated.
If a Re-Frame Selection is desired within 30 days of the initial order:
Private:
If a more expensive frame is chosen, you may pay the difference in cost. If a less expensive frame is chosen, we will refund the difference.
For the lenses, we will allow a one time redo, but this nullifies any future warranty lens redos. If a more expensive lens is chosen, the difference will be charged.
Insurance:
If a more expensive frame is chosen, you may pay the difference, and if a less expensive frame is chosen, we will refund the overage difference and a $25.00 Frame Restocking Fee.
For the lenses, we will allow a one time redo, but this nullifies any future warranty lens redos. If a more expensive lens is chosen, applicable overage fees will apply.
Insurance eligibility cannot be reinstated.
If a Re-Frame Selection is desired after 30 days, the new glasses will become a Private Pay order.
There are no refunds or insurance reinstatements after 30 days.
Contact Lens Service Fees
Our Contact Lens Fee Schedule is based on a variety of factors. These include the expected amount of time and services required to determine a particular prescription, the exact lens type, and the number of Evaluation visits deemed necessary to ensure excellent eye health and the best clarity possible with the use of this medical device.
Current Contact Lens Wearers
If you are a current contact lens wearer and we are determining a new contact lens prescription without changing type or brand of lens, the lower fee for a Contact Lens Refit is appropriate. This fee is applicable if you come in wearing your contact lenses and we know the original parameters from our records, or can obtain the information from the doctor who originally fit the lenses. This is required on an annual basis for contact lens prescriptions to remain current, and to allow replacement lenses to be ordered as needed. Please be aware that if we change contact lens types or brands, or order fitting lenses, a Contact Lens Fitting Fee will apply. This may also include an Evaluation Fee if additional visits are expected to complete the service and finalize the contact lens prescription.
New Contact Lens Wearers
If you are a first time contact lens wearer, you will initially need a Contact Lens Fitting. This involves taking measurements of the front surface of the eye, placing a trial lens on the eye to assess lens fit, checking the proper power over the trial lens and determining a contact lens prescription. If a specialty lens such as a toric, multifocal or monovision style lens is required, this is a more complicated fitting and will likely involve additional visits, so a Specialty Fitting Fee will be charged.
Evaluation visits are necessary to address any problems, determine an appropriate wearing schedule, and ensure excellent eye health throughout the wearing period with your contact lenses. This fee will be determined by the estimated number of visits necessary, and this will vary depending on the lens type and wearing schedule. For example, extended wear patients have a greater possibility of eye infections, abrasions and corneal edema. Therefore, we have a greater number of Evaluation visits over a longer period which will require a higher fee.
We truly appreciate your selection of our office to provide your contact lens care, and we strive to provide the best and most professional services available. Please do not hesitate to contact our office if you have any questions or comments, and we hope your contact lens experience is both pleasant and highly successful!
I have reviewed the contact lens fee schedule and agree to the above outlined policies.
Pupil Dilation Consent
Dilation of the pupil is a common diagnostic test to better examine the interior of the eye by providing a wider field of view. This is an essential procedure to do at regular intervals to fully assess eye health.
To dilate your pupil, eye drops must be administered, and once the drops take effect, we will examine your eyes. Dilation may cause blurred vision, especially at near distances, for usually about 3-6 hours depending on the type of drop that was used. During this time, you must exercise caution when walking down steps, driving a vehicle, operating dangerous machinery or performing other tasks that may present a risk of injury. If you have any special transportation needs, please let us know so that they can be arranged prior to dilation. Or, you may reschedule the dilation for another day which is more convenient for you at no additional charge.
Also, it is common to be light sensitive for the same period of time, and sunglasses are especially helpful. If you do not have any sunglasses, or your current pair is not dark enough, we will be happy to supply you with disposable sunwear for protection temporarily.
In extremely rare cases, there is the possibility of elevating the pressure inside your eye with dilation which is called "angle closure glaucoma". If you notice any pain after the dilation, please inform us immediately and we will recheck your eye pressure to determine if this has occurred. If so, we would refer you to have eye drops and oral medication used to lower the pressure.
I understand the risks and benefits associated with pupil dilation, and consent to have the procedure performed as recommended by my doctor.
Optomap Retinal Imaging
As part of a comprehensive eye examination, it is recommended that
ALL patients have the internal health of their eyes thoroughly evaluated every year. This is performed through either a
dilated retinal exam or
Optomap Retinal Imaging , or both. Dilation requires the use of eye drops which may blur vision for 4-6 hours and causes light sensitivity.
Our practice is pleased to provide all of our patients with the most highly advanced technology available in retinal screening today! Our ability to view your internal retinal health is now
dramatically improved with the Optomap which takes a digital image of the inside of your eye.
We strongly recommend the Optomap for the following reasons:
A highly detailed view of the back of your eye is achieved which becomes part of your permanent medical record.
Your digital image becomes a baseline which can be referenced if later changes occur.
Eye disease is more easily detected including macular degeneration, glaucoma, retinal holes and tears as well as other retinal conditions.
Systemic disease may be monitored and detected including hypertension, diabetes, certain types of cancer and many other medical conditions.
The Optomap is fast, easy and convenient, and in most cases, does not require dilation.
PLEASE NOTE THAT THERE IS AN ADDITIONAL CHARGE OF $44 (ADULTS), $28 (CHILDREN 18 & UNDER) OR APPLICABLE CO-PAY PER YOUR INSURANCE FOR THE OPTOMAP RETINAL IMAGING.
Quantify (Only if you are 45 years of age or older)
This is a new test which tries to identify which individuals might be more at risk for developing macular degeneration. This test measures the thickness of the pigment that protects the macula, the part of your eye responsible for your sharpest vision. The cost is $25.00, and includes a 6 month recheck at no charge.
Major Medical Insurance
Regarding medical insurance, we would like to take a copy of your major medical insurance card if possible. If you have a PPO, not an HMO, we may be able to take care of eye related problems such as red eyes, itchiness or eye pain. Having a copy of your insurance card will help us determine your benefits so that we might better serve you.
Acknowledgments
I have read, understand and agree to the policies outlined above.
I consent to the performing of optometric procedures agreed to be necessary or advisable.
I authorize the release of any information contained in my records for the purpose of my treatment, billing
and processing of insurance claims and I authorize payment of benefits to Foothill Optometric Group.
The duration of this document is indefinite and continues until revoked in writing.
Notice of Privacy Practices
Please check, sign, and date that you acknowledge a copy of the Foothill Optometric Group Notice of Privacy Practices has been made available to you.
Signature: Date:
Drs. Liu & Longacre, Inc. dba Foothill Optometric Group
6155 Stoneridge Drive, Suite 100, Pleasanton CA 94588
(925)-463-2150, Fax: (925)-463-1186
www.fogeyes.net Email: foothilleyes@fogeyes.net
Thank you for all your time and attention and you're done!