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Review Of Systems
Social History
Notice of Privacy, Policies and Agreement
Patient acknowledges that
It is the patient's responsibility to check if we are out-of-network with their
insurance plan prior to
their visit.
It is the patient's responsibility to file insurance claims if we are not contracted
with your
insurance company.
I understand that all charges for professional services rendered are my
responsibility. I
understand this office, if contracted with my insurance company, will file a claim
to my insurance
company on my behalf.
I authorize payment of benefits to Eric Verret OD, Inc.
Your doctor will accept the fee approved by your insurance as payment in full for
any covered
services. The patient will be responsible for any amount approved but not paid by
the insurance
as well as the full amount for all non-covered services.
I agree to assume responsibility for co-payments and deductibles as specified by my
insurance
and for the charges of any non-covered services.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE
YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE
READ
CAREFULLY.
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 âhealth 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 payments purposes
are asking you about your health or vision care plan, or other sources of payments,
preparing and sending bills or
claims; and collection unpaid amounts (either ourselves or through a collection
agency or attorney). "Health care
operationsâ means 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 operation
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 you; 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 my 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;
•Disclosures to a medical examiner to identify a dead person or to determine
the
cause of death or in funeral
directors to aid in burial or to organizations that handle organ or tissue
donations;
•Uses or disclosures for health related research;
•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
& health of members of the foreign service;
•Disclosures relating to worker's compensation programs;
•Incidental disclosures that are an unavoidable by-product of permitted uses or
disclosures;
•Disclosures to âbusiness associatesâ and their subcontractors who
perform health care operations for us and
who commit to respect the privacy of your health information in acceptance with
HIPPA;
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 health 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 communication takes the form of
face-to-face communications we
may make with individuals or promotional gifts of nominal value 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 & 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 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 disclosures 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 unable
to restrict 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
authorization.
•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 laws.
•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 give us a reason to support
your request. We may also 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,
• 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.
Your request must state how you would like to receive the report (paper or
electronically).
•To designate another party to receive your health information. If your
request for
access to 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.
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 office. Copies of this Notice
are also available upon request at
our reception area.
Notice Revised and Effective: August 15, 2022.
Download our Notice of Privacy
I hereby acknowledge that I received a copy of this medical practice's Notice of
Privacy
Practices and that I will be offered a copy of any amended Notice of Privacy
Practice at each
appointment.
RELEASE OF MEDICAL INFORMATION
I authorize release of my medical information to the following persons.
PHYSICIAN PATIENT ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to
medical malpractice,
that is as to whether any medical services rendered under this contract were
unnecessary or
unauthorized or were improperly, negligently, or incompetently rendered, will be
determined by
submission to arbitration as provided by California law, and not by a lawsuit or
resort to court
process except as California law provides for judicial review of arbitration
proceedings. Bothparties to this contract, by entering into it, are giving up their
constitutional right to have any
such dispute decided in a court of law before a jury, and instead are accepting the
use of
arbitration.
Article 2: All Claims Must be Arbitrated: It is the Intention of the parties
that this agreement
bind all parties whose claims may arise out of or relate to treatment or service
provided by the
physician including any spouse or heirs of the patient and any children, whether
born or unborn,
at the time of the occurrence giving rise to any claim. In the case of any pregnant
mother, the
term "patient" herein shall mean both the mother and the mother's expected child or
children.
All claims for monetary damages exceeding the jurisdictional limit of the small
claims court
against the physician, and the physician's partners, associates, association,
corporation or
partnership, and the employees, agents and estates of any of them, must be
arbitrated
including, without limitation, claims for loss of consortium, wrongful death,
emotional distress or
punitive damages. Filing of any action In any court by the physician or patient to
collect or
contest any medical fee shall not waive the right to compel arbitration of any
malpractice claim.
However, following the assertion of any malpractice claim, any fee dispute, whether
or not the
subject of any existing court action, shall also be resolved by arbitration.
Article 3: Procedures and Applicable Law: A demand for arbitration must be
communicated in
writing to all parties. Each party shall select an arbitrator (party arbitrator)
within thirty days and
a third arbitrator (neutral arbitrator) shall be selected by the arbitrators
appointed by the parties
within thirty days of a demand for a neutral arbitrator by either party. Each party
to the arbitration
shall pay such party's pro rata share of the expenses and fees of the neutral
arbitrator, together
with other expenses of the arbitration incurred or approved by the neutral
arbitrator, not
Including counsel fees or witness fees, or other expenses Incurred by a party for
such party's
own benefit. The parties agree that the arbitrators have the immunity of a judicial
officer from
civil liability when acting In the capacity of arbitrator under this contract. This
immunity shall
supplement, not supplant, any other applicable statutory or common law.
Article 4: General Provisions: All claims based upon the same Incident,
transaction or related
circumstances shall be arbitrated in one proceeding. A claim shall be waived and
forever barred
if (1) on the date notice thereof Is received, the claim. If asserted in a civil
action, would be
barred by the applicable California statute of limitations, or (2) the claimant
faills to pursue the
arbitration claim In accordance with the procedures prescribed herein with
reasonable diligence.
With respect to any matter not herein expressly provided for, the arbitrators shall
be governed
by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice
delivered to the
physician within 30 days of signature. It is the intent of this agreement to apply
to all medical
services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover
services rendered
before the date it is signed (induding, but not limited to, emergency treatment)
patient should
check I agree below:
Effective as of the date of first medical services.
If any provision of this arbitration agreement is held invalid or unenforceable, the
remaining
provisions shall remain in full force and shall not be affected by the invalidity of
any other
provision.
I understand that I have the right to receive a copy of this arbitration agreement.
By my
signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY
ISSUE OF
MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING
UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Patient Consent Form - Escondido Eyecare
Please read carefully and check the designated checkbox to confirm that you had read
and
understood each section of this consent form.
Coverage Terms
Your insurance policy is an agreement between you and your insurance company. It is
your
responsibility and not that of Dr. Verret's office to know your policy terms and
conditions. We try
to verify your eligibility and benefits as a courtesy. However, we would know the
exact details of
payments only after claims are processed. check I agree below.
Authorization
If your insurance company requires authorization from your Primary Care Provider, it
is your
responsibility to obtain the relevant authorization before your visit. Otherwise,
the cost of your
visit will be your responsibility.
Insurance Company Disputes
The negotiation of payments that are due to your service providers or the settling
of any
disputes that may arise between you and your insurance company is entirely your
responsibility.
Payment/Outstanding Balances
All payments and copays are before receiving the service. Any outstanding balances
should be
settled before the visit of the physician. All your account balances have to be
current. We can
work with you on convenient payment plans, should you require so.
Collection Policy
You will be responsible for interest and penalties if payments are not settled upon
receiving the
monthly billing statement. Any unpaid debt to Dr. Verret's office is handled by a
third party
collection company. If your account is sent to collections, you are responsible for
settling any
attorney fees, interest, or penalties applicable by law. You may even be discharged
from the
practice if your account is sent to collections.
Copy of Medical Records or Disability Paperwork
If you need any medical records from us, please send a written request to authorize
the release
of such records. We charge $25 upfront for copies of medical records or disability
paperwork.
Please note that processing takes 1 - 2 weeks from the date of receipt of such
requests.
Late to Appointments
If you are more than 15 minutes late for your appointment, please understand that
you may
have to reschedule your appointment.
Cash Agreement
I acknowledge that I am responsible for the cost of my visit at the Escondido
Eyecare and/or
any testing done if my insurance information is not provided at the time of visit or
insurance
information is inaccurate, inactive or ineligible.
If you have any concerns please do not hesitate to contact the office at (760)
747-7979.
Consent to Video Recording
I understand that Escondido Eyecare has video surveillance in its office spaces for
quality
assurance purposes. I consent to video recording while I am at Escondido Eyecare's
premises.
Consent to Retinal Scan or Dilation
As part of your eye exam, your eye doctor can evaluate your retina in 3 different
ways:
1 DILATION
We can use dilating drops to enlarge your pupils ("dilation"). This allows for a
complete
evaluation of your central and peripheral retina.
Dilation involves instilling eye drops for the purpose of enlarging the pupils of
the eyes to better
check the health of the inside of the eyes.
The pupils are simply an opening to the inside of the eye. Looking through an
undilated pupil is
similar to looking into a room through a keyhole in the door; the doctor may see
only about 20%
of what is inside.
However, looking through a dilated pupil is like looking into a room through an open
door; the
doctor gets a complete view of the inside of the eye.
Dilation allows the doctor a better view of the peripheral retina and find diseases
that would
have been missed otherwise.
However, no photos are taken.
Patients with high prescriptions, past retinal problems (i.e. retinal
detachment/tears), sudden
cloudiness of vision, especially in one eye, "curtain or veillike" obstruction of
vision, a sudden
onset of many "floaters" or flashing lights off to the side of your vision,
diabetes, and high blood
pressure are STRONGLY advised to have their eyes dilated yearly.
In addition, patients with a family history of glaucoma, macular degeneration or
blindness should
also be dilated annually.
Side Effects
A wait time of 30 minutes is required to allow the drops to take effect before the
doctor can
examine your eyes.
Some blurring of vision and glare because of enlarged pupils for about 3 to 6 hours.
You should
not operate heavy equipment or drive an automobile.
Difficulty with near reading for 2 to 3 hours. The focusing ability is impaired and
may cause a
slight headache if you try to read and may prevent you to work during this time.
Sensitivity to light.
Burning upon instillation of drops.
Induced ocular hypertension (high pressure inside the eyes). Rare cases have been
reported in
which redness and sharp pain are experienced.
2 OPTOMAP WITH THE OPTOS
We can evaluate your retina by taking a retinal scan (picture of the retina).
With this option, we will be able to keep photos on file, which makes it very easy
to compare
from one year to the next.
Side effects
NONE
3 BASIC RETINAL CAMERA
The doctor will only be able to see the central retina and many eye and/or systemic
diseases
can be missed.
Side effects
NONE
In order to provide the most comprehensive exam possible we request that all of our
patients
have a dilated eye exam or have a retinal scan performed.
REFUSAL TO HAVE YOUR PUPILS DILATED OR HAVE A RETINAL SCAN PERFORMED
MAY CAUSE YOUR DOCTOR TO BE UNABLE TO DETECT CERTAIN DISEASES.
I understand that dilation of my pupils or a retinal scan is a very important
diagnostic tool that
aids the doctor in determining my state of health. I understand that by refusing
dilation or retinal
scan, I risk having a sight-threatening disorder or other disease left undiagnosed.
PLEASE CHOOSE ONE OF THE FOLLOWING: