Outpatient Division Screening for COVID-19
1. As of today, are you COVID-19 positive or actively infected with COVID-19 virus?
Acknowledgement and Assumption of Risk
Jade Opticalhas taken all precautions recommended by the Centers for Disease Control and Prevention for business to provide services to customers during the COVID-19.Additionally, Jade Opticalhas been screening our employees before every work shift to ensure that no employee is suffering any of the known symptoms of COVID-19, including running a fever, having a dry cough, or experiencing shortness of breath. However, it is also knownthat those without symptoms may still be capable of infecting others as an asymptomatic individual with COVID-19and despite precautions taken the virus may still be present and capable of infecting individuals.
Knowing this information, I voluntarily elect to continue with my scheduled appointment with JadeOpticaland I hereby agree to accept and assume any and all risks of personal injuryor death.
Waiver of Liability and Indemnification
In consideration for being treated by Jade Optical,on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I:
a. waive, release, and discharge Jade Optical,
its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced appointment; and
b. defend, indemnify, and hold harmless Jade Optical,
its agencies, officers and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of Jade Opticalwillful or intentionalnegligence.
This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.
I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreementor that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have read this form and fully understand that by signing this form I am giving up legal rights
and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my appointment. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
Read Before SigningRead Before Signing
Signature (Parent / Guardian):
Retinal Photo Test
Digital Retinal Photo Screening
for Detection of Medical Eye Disorders
The Digital Retinal Photo Screener takes a photo of the inside portion of the eye. No eye drops, no discomfort!
The Digital Retinal photo can detect ocular diseases such as:
The Digital Retinal photo can also medical conditions associated with your general health such as:
The doctor strongly recommends this screening test, especially for first time patients. This allows for a more thorough examination of the eye. The digital photo also serves as baseline documentation that allows the doctor to monitor your health every year with more accuracy and detail. This photo stays on your file for life and can easily be shared with other doctors such as Primary Care Doctors and Ophthalmologists when needed for better patient care. Our staff will happily provide you with a digital copy for your records upon request.
There is a fee of $39.00 for the digital photo screening exam. You'll be given a receipts, as your insurance plan may reimburse you for this medical procedure. Our staff will let you know if your insurance covers this service. This screening test does NOT substitute a dilated eye exam but helps view the patient's ocular health with more detail and thoroughness when looking through a non-dilated regular pupil.
I have read and understand the information regarding the Digital Retinal Photo Screener.
Check the appropriate line below, sign and date:
YES, I do want the Digital Photo Exam
NO, I do not want the Digital Photo Exam
Policies, Consent and Submit Data
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH 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 HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this
Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy
practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we
replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted
by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health
information that we maintain, including health information we created or received before we made the changes. In the event we make a
material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time.
For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the
end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment
to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation
between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d)
Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing
and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its
responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage,
adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities;
and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare
operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us
written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in
effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in
Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written
authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will
never sell your health information without your prior authorization.
To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this
Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your
healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in
our professional judgment.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or
locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition,
or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an
opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health
information based on a determination using our professional judgment disclosing only health information that is directly relevant to the
person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make
reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms
of health information.
Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim
of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances.
We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health
information of inmate or patient under certain circumstances.
Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and
services that may be of interest to you.
Access: You have the right to review or get copies of your health information, 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 practicably do so. You must make a request
in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the
end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access
by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for
providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a
fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other
activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a
12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are
not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request in writing that we communicate with you about your health information by
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.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why
the information should be amended. We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request
you made to amend or restrict the use or disclosure of your 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 also may 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 Services upon request. We support your right to the privacy of your 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.
Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!