I authorize the release of any medical information necessary to provide the most beneficial and complete eye health examination. I acknowledge that Wyntre Brooke Eye Associates, Inc. will attempt to verify plan eligibility for services and/or materials prior to the exam. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. I understand it is my responsibility to check with the plan administrator if I have any questions regarding my eligibility. I understand that I am financially responsible for all charges whether or not paid by insurance. I understand the Exam Co-Payment is due at the time services are rendered. When materials are ordered (glasses or contact) a 50% deposit must be paid with the remaining balance due when materials are received. I understand that if there is an unpaid balance beyond 30 days, interest will accrue. My account may be turned over to collections and I am responsible for all collections fees that will be added.

 

The following is a brief summary of your rights and our responsibilities as detailed in the attached Notice of Privacy Practices (the "Notice"). This Summary is for your convenience and is not a substitute for reading the entire Notice (available upon request) and does not modify the terms of the Notice.

1. Uses and Disclosures of Your Health Information. We may use the information we develop and collect for treatment by our practice or disclose the information to others to whom we refer you for treatment, for payment for these services and for certain health care "operations" such as improving the competence and quality of our staff and business planning and management. We may disclose your information to our business associates such as medical transcriptionists, billing services and others who assist in the operations of our practice. We may call you to remind you of appointments and may leave a message on your answering machine if you have one. We may also disclose information to your family about your location and general condition. If you are available and able, we will ask your consent first. We may also use your information to recommend products or services related to your care. Your medical information may be disclosed without your authorization as required by law, for public health purposes, healthcare oversight, including audits and investigations, medical research, judicial and administrative proceedings, subject to the limits imposed by state and federal law, and certain other purposes as specified by law.

2. Other Uses and Disclosures. Except as described in the Notice, we will not use or disclose your medical information without your written authorization. You can revoke an authorization at any time, except to the extent that we have already taken action in reliance on the authorization.

3. You're Health Information Rights. You have a number of rights under state and/or federal law which are subject to the terms and conditions specified in the Notice: 

a) You may request restrictions on certain uses and disclosures of your information

b) You may request that you receive your information from us in a certain way

c) You may inspect and copy your medical records

d) You may request an amendment to any record you believe is inaccurate

e) You may request an accounting of disclosures made of your records

4. Changes to the Notice. We reserve the right to change the Notice. If we do so, we will post it in our office, [and on our website] and provide a copy upon request.

5. Complaints. You may file a complaint to our Privacy Official whose name is above or with the federal government as detailed in the Notice. You will not be penalized for filing any complaint.

 

 

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.