Policies, Consent, Submit Data
NOTICE OF PRIVACY PRACTICES
Our practice is committed to educating our patients about healthcare issues that
affect them. As a result, we are providing you with general information about the
Privacy Ruler, a federal regulation of the Health Insurance Portability
and Accountability Act of 1996 (HIPPA) along with a brief overview of our Notice of
Privacy. We are complying with the HIPPA's regulations.
What is HIPPA and how does the Privacy Rule affect you?
When the Health Insurance Portability and Accountability Act (HIPPA) was passed in
August 1996 this gave the federal government the ability to mandate how healthcare
plans, providers and agencies send a patient's personal information
as it relates to healthcare. The Privacy Rule was created to protect your rights as a
patient of our practice and we are required by law to be compliant with this regulation
on April 14, 2003. Under this rule you are guaranteed access
to your medical records, allowed control over how your protected health information is
used and disclosed and allowed to take action if your privacy is compromised by
following the practice's policy. Our practice is dedicated to maintaining
the privacy of your personal information.
What is Individually Identifiable Health Information (IIHI)?
Any health information you provide our practice, including your mailing address.
Information that is created and retained by our practice or received by another
healthcare provider that relates to treatment, payment and/or that identifies
you as an individual.
What is the Notice of Privacy Practice (NPP)?
Our practice has an official Notice of Privacy Practice (NPP) posted in our waiting
room informing our patients about their rights surrounding the protection of your IIHI
and our obligations concerning the use and disclosure of your
IIHI. This notice applies to all records created or retained by our practice. We can
update our Notice Privacy Practices at any time. It will be posted in our waiting room
and you can ask for a copy of the current notice at any time.
The following categories describe the different ways in which we may use and disclose
your IIHI:
Treatment Payment Appointment Reminders Release of Information to Referring Sources
* Treatment Options Disclosures Required by Law Health Care Operations * Health Related
Benefits and Services Hearing Aid Companies
The following
categories describe unique situations in which we may use or disclose your IHII:
Public Health Risks * Health Oversight Activities * Lawsuits and Similar Proceedings *
Law Enforcement * Deceased Patients * Workers Compensation * Serious
Threats to Health and Safety Research * Military National security * Inmates * Organ and
Tissue Donation
What are your rights concerning your Individually Identifiable Health Information
(IIHI)?
You have rights regarding the IIHI that we maintain about you. In our Notice of
Privacy you can view the policies and procedures you will need to follow for the areas
listed below.
1. Confidential Communications
2. Requesting Restrictions
3. Inspection and Copies
4. Amendment
5. Accounting of Disclosures
6. Right to a Paper Copy of this Notice
7. Right to File a Complaint
8. Right to Provide an Authorization for Other Uses and Disclosures
If you have any questions regarding this notice or our health information privacy policies,
please contact: Peter Charron, OD of Charron Vision Therapy: 1151 Ellis Street Suite. 103 Bellingham, WA 98225
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OUR POLICY OF CARE & PAYMENT
Our goal at the Charron Vision Therapy is to provide the best vision
care service and products that satisfy our patients' needs at a reasonable
price.
FULL PAYMENT FOR PROFESSIONAL SERVICES AND/OR MATERIALS IS DUE AT TIME OF SERVICE.
Acceptable forms of payment include cash, personal check, Visa, Mastercard &
debit cards. A $30 FEE WILL BE CHARGED FOR NSF CHECKS.
Unpaid balances on accounts will be invoiced through email.
A 3.0% late penalty will be added to any uncollected balance after 30 days from
the due date.
Any unpaid balance that is over 90 days late will be sent to a collections agency
unless other agreements with the office have been made in writing.
What if I Have Insurance? ***About Your Insurance***
There are two types of health insurance that will help pay for your eye care
services and optical products. You may have both types and Charron Vision Therapy may accept plans in both categories.
Vision plans only cover routine vision wellness exams, along with eyeglasses and
contact lenses. Vision plans do not cover medical eye care (the diagnosis and
management or treatment of eye health problems.
Medical insurance must be used for medical eye care, including therapy and
rehabilitation.
If you have both types of insurance plans it may be necessary for us to bill some
services to one plan and some services to the other.
Please provide your insurance cards to our staff member so we can make a copy. We
need to have your medical insurance on file for future billings to your insurance.
Our clinic is contracted with a variety of insurance networks. All insurance
eligibility must be presented and confirmed prior to the services. If
eligibility for services cannot be verified, you will be responsible for payment
in full
for all services and materials at the time of your visit. All fees are the full
responsibility of the patient/parent/guardian. If our office is contracted with
your insurance, our office will file an insurance claim (HCFA 1500) on
your behalf. However, it is your responsibility to pay in full for any services
or materials not covered by your insurance plan. If you prepay for any service
or materials, any insurance payments we receive at a later date will be
credited to your account and/or refunded to you. If there are fees which are not
collected on the date of service and are not paid by your insurance, we will
bill you for them, such as deductibles, co-pays or non-covered services.
Insurance codes for pre-determination of benefits will be supplied upon request.
Eyeglass and Contact Lens Return Policy:
- Professional fees, such as therapy, exam fees, or contact lens
evaluation/fitting fees, represent payments for services that were rendered
(even if not successful) and are non-refundable.
- Frames may be returned for exchange within 30 days if in perfect condition.
The new charge will include the cost of the new frame less the cost of the
returned frame. Note: New lenses are often required if the new frame is
larger. If the frame requires new lenses, charges on the lenses will include
the full cost of the new lenses plus an additional surcharge of 20% of the
cost of the lenses.
- Prepackaged contact lenses may only be returned if the original packaging is
not opened or written upon.
Eyeglass Rx Changes:
- For prescriptions written by other doctors: Eyeglass lenses will be remade
one time at no charge if the prescribing doctor provides a new prescription
in writing within 30 days of dispensing. Rx changes after one free remake or
after
30 days will be charged the usual lens price.
- For prescriptions written by doctors at Charron Vision Therapy: An
office visit to recheck the fitting/prescription will be provided and new
lenses will be made at no charge within 30 days of dispensing. Recheck
visits after
30 days will be charged the usual fee for a refraction test.
- If a Charron Vision Therapy prescription is filled elsewhere and an Rx
change is needed, we will not be responsible for any charges incurred. Most
reputable optical dispensaries allow doctor Rx changes at no charge, but it
is
up to the patient to inquire about such policies in advance of purchase.
Progressive Addition Lens Non-Adapt Policy:
- All progressive addition lenses (also called invisible or no-line
multifocals have a slight optical distortion in the outer portions of the
lens, which can make some objects appear bowed or curved, or can cause a
feeling of motion
when the head is turned. The reading zone of progressive lenses is wide
enough for most purposes, but it may be narrower than other bifocal styles.
While most people are not bothered by these characteristics, some will find
it
unacceptable even after a one to two week adaptation period. If you cannot
adapt to progressive addition lenses, we will make new lenses in any other
design that you wish, within 30 days of dispensing, at no charge. Since the
original
lenses were a custom prescription item, there are no refunds of the
difference in cost if the remade pair is of lesser value.
Policy for Making New Lenses for a Patient's Old Frame or Frame Purchased
Elsewhere:
- Charron Vision Therapy cannot be responsible for breakage when we
reuse a patient's old frame or frame purchased elsewhere to manufacture and
insert new lenses.
- Charron Vision Therapy will use the utmost care if we accept a
patient's frame, but in a small percentage of cases, the frame parts or
material will be worn or brittle to the point that it will not support a new
lens.
- Older frames are usually discontinued by the manufacturer and replacement
parts are generally not available. Putting new lenses into an old frame may
create a pair of glasses that cannot be repaired later.
- If a patient's frame breaks during our handling, the purchase of a new frame
is the patient's expense. Charron Vision Therapy may have to discard
the first pair of lenses made for the original frame, but no additional
charge will be applied for lenses.
***It is understood that should it become necessary for my account to be turned over
for collections, I will be liable for any and all resulting collections and/or legal
fees incurred. It is understood that failure on my part to adhere to this payment
agreement will result in a break from treatment.
I acknowledge that I have read and received a copy of the foregoing agreement. I
consent to treatment and I assume all financial responsibility for all treatment
expenses.