Primary Insurance

Insurance Information

Insurance Name:	None Aetna Blue Cross Blue Shield of Illinois Blue Cross of California Community Health Plan of WA DSHS Eyemed First Choice Health Network Group Health HMA Lifewise Health Plan of WA March Vision Molina New Insurance Northwest Benefits Network Peace Health Premera Premera Blue Card Regence BSWA Tricare United Health Care Vision Service Plan
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Privacy And Payment Policy

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 Northwest Vision Development Center: 1616 Cornwall Ave Ste. 105 Bellingham, WA 98225 ______________________________________________________________________________________________________________________________________________________

OUR POLICY OF CARE & PAYMENT

Our goal at the Northwest Vision Development Center 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.

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 NW Vision Development Center 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.
• Eyeglass lenses are custom made devices and are not refundable, but we will be happy to correct any problems you may experience. See the section below on Doctor's Rx changes for more information. 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 NW Vision Development Center: 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 NW Vision Development Center 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:

• We cannot be responsible for breakage when we reuse a patient's old frame to manufacture and insert new lenses.
• We 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. We may have to discard the first pair of lenses made for the original frame, but no additional charge will be assessed for lenses.

***It is understood that the Northwest Vision Development Center reserves the right to send to collections any account when lack of effort to satisfy unpaid balance(s) is shown. 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.

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