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 IT CAREFULLY.
Your “health information,” for purpose 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 a ‘’health information’ in this Notice).
We are required by 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 the 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 purpose 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 manage 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 all. Such uses or disclosures are:
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 disclosure 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 form 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 note 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 OTHER USES AND DISCLOSURES
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 disclosure 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 your 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:
Our contact person for all questions, requests or for further information related to the privacy of your health information is: Anne Carlsson 480-988-4131
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.
Contact lenses are medical devices, regulated by the FDA. This means that the doctor has to evaluate the health of your eyes and the fit of your contacts every year in order to determine the optimum prescription for your eyes.
Contact lens examinations are required on a yearly basis. These tests are done to make sure your eyes are healthy, that the lenses fit your eyes properly, and to ensure that you are seeing as clearly as possible.
All contact lens patients will be charged a contact lens fitting and evaluation fee. The fee varies based upon the complexity of the contact lens fitting and chair time needed to assess and finalize the fitting. Insurance companies require that we bill contact lens fitting/evaluation charges separately from your comprehensive eye examinations. In most cases, insurance companies consider contact lenses “not necessary” and they will not cover these charges. The services received for this fee include the fitting/refitting and evaluation for contact lenses, tear film/corneal health analysis, all contact lens follow-up visits with the doctor for 60 days, any diagnostic lenses used.
For First Time Wearers: An additional fee of $20 will be applied to the fitting for all new contact lens wearers due to additional time involved with fitting these patients.
Some vendors offer rebates when purchasing an annual supply of lenses and we offer an additional "volume discount" for most annual purchases. Once fitting is completed, this option is presented when available
to the patient for additional savings.
Contact Lens Evaluation: The contact lens evaluation is not part of the standard comprehensive eye exam. There is an additional fee for a contact lens evaluation/fitting and contact lens prescription update. These fees are determined based on the type of lenses you are fit with and need to be paid at the time of your copay.
*Please only sign below if you're wanting contacts at your next visit*
REFUND& EXCHANGE POLICY
We have a “YES” policy within the first 30 days after dispensing glasses or contacts. Please keep in mind all products must be picked up within a timely manner after receiving communication that your product is in. Within the 30 days you are eligible for a full refund on glasses. A full refund will be granted for contacts as long as the product is unopened and/or damaged. Choosing a different frame is also warranted in this time period. The credit will go towards your new frame. After, the 30 day time period a restocking fee of $150.00 will be issued on any product being returned. A doctor’s change is allowed within 60 days of dispensing. After, the 60 days if there is no documentation or attempt to correct the situation no prescription change will be granted.
LIMITS OF INSURANCE COVERAGE AND ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
Our Doctors and staff are dedicated to assisting you in making sure that your health insurance will reimburse for all covered services. Your health insurance and vision rider may not pay for all of your health care costs; your employer and your insurance company largely determine your health care benefits. Health insurance only pays for covered items and services when their rules are met.
It is your responsibility to be aware of your insurance coverage policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. We must verify that your health and vision coverage are valid before the date of your visit. It is your responsibility to provide us with accurate information to accomplish this, including your insurance card numbers and social security number if needed. No coverage will be accepted after services are rendered.
We will make every effort to verify your coverage prior to your visit. The benefits given are an estimate only. Any difference after the claim has been processed will be your responsibility.
CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES
Co-payments, co-insurance and deductibles are the responsibility of the patient/guardian and are due at the time of the visit. These are determined by the contract you have with your insurance carrier.
If your plan requires, it is your responsibility to obtain referrals from your Primary Care Physician prior to your visit.
You are responsible for responding to insurance company requests for further information. Failure to respond to your insurance company’s requests will result in denial of the claim and will make you responsible for payment.
Vision riders, which have a limited benefit, may only be used for visits that are strictly vision related. Any visit that is of a medical nature must be billed to the medical insurance.
Some medical insurers will not pay for refraction (the act of finding the glasses prescription). If your carrier is one of these you may be asked to pay for that service.
A 48-hour notice of cancellation or rescheduling of an appointment is required. Changes made without a 48-hour notice may be subject to a $45 charge.
DIGITAL RETINAL PHOTOS
Carlsson Family Eye Centers policy is to complete retinal photos with every patient to ensure the health of the eyes and a complete comprehensive evaluation. These photos are a valuable screening tool that is a copay of $35 in the office. Some insurance companies, when accompanied with a medical diagnoses, will cover this procedure and many will not.