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). Examples of how we use or disclose 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. The most common reason why we use or disclose your health information is for treatment, payment or health care operations. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS This Notice describes how we protect your health information and what rights you have regarding it. We are obligated by law to give you notice of our privacy practices. We respect our legal obligation to keep health information that identifies you private. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW VOU CAN GET ACCESS TO THIS INFORMATION. I have read and understand the financial policy above. Insurance benefits will not be reinstated. Failure to pick up materials paid in full after sixty (60) days will result in return of the materials to our vendor. It is the patient's responsibility to pick up glasses, accessories or contact lenses within sixty (60) days of full payment. Orders cannot be delivered until they are paid in full. Complete payment is required within sixty (60) days of the order. The balance is due in full when glasses or contact lenses are delivered. Glasses and contact lens orders not involving insurance require at least a 50% deposit before orders can be processed. Any portion of services not covered by insurance deemed the patient's responsibility after the insurance has been processed will be billed to you. Any portion of professional services not covered by insurance is due in full at the time of the visit. I voluntarily consent to diagnostic procedures and medical treatment by my doctor and his/her assistants, as may be necessary in my doctor’s judgment.įinancial Policy: Payment of all professional services is due in full at the time of the visit.
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