Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 8 contracts
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name: Signature: 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx LASIK Screening Questionnaire Please circle YES (Y) or NO (N) to applicable questions Do you have trouble seeing far away or up close? How long has your prescription been stable? Do you wear contact lenses? Y N If YES, date last worn: What problems are you experiencing with your glasses and/or contacts? How long have you been thinking about having LASIK? If you are a good candidate, how soon would you like to have the procedure? What (if anything) in the past has stopped you from proceeding with LASIK? Is there a chance you could be pregnant or nursing? Y N Are you planning to be within the next 6 months? Y N OCULAR HISTORY SYSTEMIC HISTORY Y N Keratoconus Y N Collagen/Vascular disease Y N Vascularized corneas Y N Lupus erythematosus Y N Corneal Erosion Y N Ankylosing spondylitis Y N Herpes Simplex Virus Keratitis Y N Cranial arteritis Y N Lazy Eye Y N Polyarteritis nodosa Y N Dry eyes Y N Xxxxxx’x syndrome Y N Exophthalmos Y N Relapsing polychondritis Y N Lagophthalmos Y N Adult rheumatoid arthritis Y N Conjunctival edema Y N Juvenile rheumatoid arthritis Y N Lid disease Y N Scleroderma Y N Flat cornea (< 41 mm) Y N Xxxxxxx’x syndrome Y N Steep cornea (> 46 mm) Y N Xxxxxxx’x disease Y N Uncontrolled glaucoma Y N Crohn’s disease Y N Macular Degeneration Y N Ulcerative colitis Y N Cataract Y N Imitrex (sumatriptan) Use Y N Diabetic Retinopathy Y N Cordarone (Amiodarone) Use Y N Surgery or Injury to the Eye Y N Accutane (Isotretinoin) Y N Radiation Therapy Y N Previous scleral buckle Other: What I am looking for in LASIK/PRK with Xxxxxx Eye (Please rate these in order of most important 1 to 6) Financing Facility Technology Experience and Reputation of Surgeon Cost Results All of the above information is true and accurate to the best of my knowledge. I understand that this is a preliminary screening and does not constitute a true eye exam. Further examination is required to ensure that I am a candidate for Refractive Surgery. Patient Signature: Date:
Appears in 4 contracts
Your Rights. Following is a statement of your rights with respect to your protected health informationinformation and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physicians practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee to copy your records. Under federal law, however, you may not inspect or copy the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, ; and protected health information laboratory results that is are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest does agree to permit the requested restriction, we may not use and disclosure of your protected health information, or disclose your protected health information will not be restrictedin violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You then have the right may request a restriction by providing a written letter to use another Healthcare Professionalyour provider. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the right basis for the request. Please make this request in writing to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronicallyour Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the right disclosure, to change family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the terms privacy rule) or correctional facilities, as part of this notice and will inform you by mail of any changesa limited data set disclosure. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before receive specific information regarding these disclosures that occur after April 14, 2003. 0000 XX Xxxxxxx 00 XThe right to receive this information is subject to certain exceptions, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxxrestrictions and limitations., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 2 contracts
Samples: Consent Agreement, Consent Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect information and copy your protected health information. Under federal law, however, a brief description of how you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health informationexercise these rights. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy PracticesNotice. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician Citizens is not required to agree to a restriction that you may request. If physician Citizens believes it is in your best interest to permit use and disclosure of your protected health information, or that it is not reasonably feasible to comply with your request, your protected health information will not be restricted. If Citizens does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment as part of provision of your services. You then have the right may request a restriction by submitting a written request to use another Healthcare ProfessionalCitizens. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests that are feasible to implement. We may also condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. You have the right make this request in writing to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronicallyCitizens. You may have the right to have your physician Citizens amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You may request an amendment by submitting a written request to Citizens. You have the right to receive an accounting of certain disclosures we have made, if any, of your personal and protected health information. We reserve the This right applies to change the terms disclosures for purposes other than provision of PERS services, treatment, payment or healthcare operations as described in this notice and will inform you by mail Notice of any changesPrivacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You then have the right to object or withdraw as provided in receive specific information regarding these disclosures that occurred after August 1, 2012. The right to receive this noticeinformation is subject to certain exceptions, restrictions and limitations. Complaints To request an accounting of disclosures, you may contact Citizens. You may complain have the right to us or to the Secretary obtain a paper copy of Health and Human Services this Notice from us, upon request, even if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA agreed to accept this Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxxelectronically., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 2 contracts
Samples: Service Agreement, Service Agreement
Your Rights. Following is a statement of your rights with respect to your protected health informationinformation and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, ; and protected health information laboratory results that is are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest does agree to permit the requested restriction, we may not use and disclosure of your protected health information, or disclose your protected health information will not be restrictedin violation of that restriction unless it is needed to provide emergency treatment. You then have the right With this in mind, please discuss any restriction you wish to use another Healthcare Professionalrequest with your physician. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the right basis for the request. Please make this request in writing to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronicallyour Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the right disclosure, for a facility directory, to change family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the terms privacy rule) or correctional facilities, as part of this notice and will inform you by mail of any changesa limited data set disclosure. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before receive specific information regarding these disclosures that occur after April 14, 2003. 0000 XX Xxxxxxx 00 XThe right to receive this information is subject to certain exceptions, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I restrictions and limitations. You have reviewed and/or requested the right to obtain a paper copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) this notice from us, upon request, even if you have agreed to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include accept this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:notice electronically.
Appears in 1 contract
Samples: Hipaa Data Use Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name: Signature: FINANCIAL POLICY CONSENT FORM The doctors and staff at Xxxxxx Eye & Laser Center (NELC) would like to thank and welcome you to XXXXXX EYE. Our goal is to provide you with XXXXXX EYES! Please read the Financial Policy, outlined below, and ask any questions you may have, and initial where requested:
Appears in 1 contract
Samples: Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. PHI: You have the right to inspect and copy get copies of your protected health information. PHI: Under federal law, however, you may my not inspect or copy the following records; psychotherapy notes; , information compiled in reasonable anticipation of, of or use in, in a civil, criminal, or administrative action or proceeding, and protected health information PHI that is subject to law that prohibits access to protected health informationPHI. You have Have the right to request a restriction of your protected health information. PHI: This means you may ask us not to use or disclose any part of your protected Protected health information Information for the purposes of treatment, payment payment, or behavioral healthcare operations. You may also request that any part of your protected health information Protected Health Information not be disclosed to family members or friends who may be involved in your care case or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician counselor is not required to agree to a restriction that you may request. If physician the counselor believes it is in your best interest to permit use and disclosure of your protected health informationPHI, your protected health information PHI will not be restricted. You then have the right to use another Healthcare Professionalhealthcare professional. You have Have the right to request to receive confidential communications information from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon . Upon request, even if after you have agreed to accept this notice alternatively by alternative means (i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal). You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health informationPH. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain revoke your consent or authorization for you counselor to us or to the Secretary of Health use and Human Services if you believe your privacy rights have been violated by usdisclose PHI. You may file a complaint with us by notifying our privacy contact must submit your revocation in writing to myself or the Privacy Officer of Xxxxx X. Xxxxx, Ph. D. & Associates. Your counselor is permitted to use and disclose your PHI based on your consent until your revocation is received. If you revoke your consent, your counselor reserves the right to refuse to provide further treatment to you, on the basis of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) refusal to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission allow us to share appointmentinformation for the purpoases of treatment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans payment, and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:healthcare operations.
Appears in 1 contract
Samples: www.darrenwlove.com
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. : Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; , information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. : This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to applyapply in writing. Your physician physician/dentist is not required to agree to a restriction that you may request. If physician physician/dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications communication from us by an alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician physician/dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaintcomplain. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before became effected on April 14, 2003. 0000 XX Xxxxxxx 00 XWe are required by law to maintain the privacy of, Xxxxxxxand provide individuals with, XX 00000 (863) 385this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our main phone number 000-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908000-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing 0000.. Signature below is only acknowledgement that you have received this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of our Privacy Practice - Disclosures of Protected Health Information Print Practices: PLEASE PRINT Patient Name:
Appears in 1 contract
Samples: Appointment Agreement
Your Rights. Following is a statement of your rights with respect to your protected health informationinformation and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, ; and protected health information laboratory results that is are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest does agree to permit the requested restriction, we may not use and disclosure of your protected health information, or disclose your protected health information will not be restrictedin violation of that restriction unless it is needed to provide emergency treatment. You then have the right With this in mind, please discuss any restriction you wish to use another Healthcare Professionalrequest with your physician. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the right basis for the request. Please make this request in writing to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronicallyour Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the right disclosure, for a facility directory to change family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the terms privacy rule) or correctional facilities, as part of this notice and will inform you by mail of any changesa limited data set disclosure. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before receive specific information regarding these disclosures that occur after April 14, 2003. 0000 XX Xxxxxxx 00 XThe right to receive this information is subject to certain exceptions, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I restrictions and limitations. You have reviewed and/or requested the right to obtain a paper copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) this notice from us, upon request, even if you have agreed to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include accept this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:notice electronically.
Appears in 1 contract
Samples: Usage Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and receive a copy of your protected health information. Our practice will accept such requests in writing. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Under federal law, however, you may not inspect or receive a copy of the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, ; and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician therapist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to obtain a paper copy of this notice from us. You have the right to request to receive confidential communications from us by an alternative means or at an alternative location (for example, home or office phone). We will agree to all reasonable requests. You have the right to request a restriction on the disclosure of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. We are not required to agree to your request, and we may decline if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree unless a law requires us to share that information. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in you care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your therapist is not required to agree to a restriction that you may request. If a therapist believes it is in your best interest to permit use and disclosure of your protected health information, your health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve You can ask for a list (accounting) of the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or times we’ve shared your health information for six years prior to the Secretary of Health date you ask, who we shared it with, and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaintwhy. We will not retaliate against include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for filing free but will charge a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14reasonable, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385cost-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxxbased fee if you ask for another one within 12 months., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: Card Authorization Agreement
Your Rights. Following is a statement of your rights with the respect to your protected health information. You have the right to inspect Inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; following: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purposes purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Health care Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon . Upon request, even if you have agreed greed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: Hipaa Agreement
Your Rights. Following is a statement The following are statements of your rights with respect to your protected health information. You have the right to inspect and copy have copies of your protected health information. Under federal law, however(FEES MAY APPLY) – Pursuant to your written request, you may not have the right to inspect or copy the following records; psychotherapy : Psychotherapy notes; , information compiled in reasonable anticipation of, or use used in, a civil, criminal, criminal or administrative action or proceeding, and protected health information restricted by law, information that is subject related to law medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or another person, or information that prohibits access to protected health informationwas obtained under a promise of confidentiality. You have the right to request a restriction of your protected health information. – This means that you may ask us not NOT to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a your requested restriction except if you request that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your not disclose protected health information will not be restricted. You then to your health plan with respect to healthcare for which you have the right to use another Healthcare Professionalpaid in full out-of-pocket. You have the right to request to receive confidential communications communications. - You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, us upon request, even if you have agreed to accept this notice alternatively alternatively. (i.e. electronically. ) You may have the right to have your physician amend request an amendment to your protected health information. - If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures. - You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures we pursuant to an authorization, for the purposes of treatment, payment, healthcare operations or required by law that occurred prior to April 14th, 2003, or (6) years prior to the date of the request. You have made, the right to receive notice of a breach. - We will notify your if any, of your unsecured protected health informationinformation has been breached. You have a right to obtain a paper copy of this notice from us, even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will inform notify you by mail of any changes. You then have such changes on the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaintfollowing appointment. We will not retaliate against also make available copies of our new notice if you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxxwish to obtain one., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: bcapediatrics.com
Your Rights. Following is As a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, howeverpatient, you may not inspect or copy have certain rights regarding your access to, and the following records; psychotherapy notes; information compiled in reasonable anticipation accuracy of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health informationyour Protected Health Information. These rights include: You have the right to request a restriction on certain uses and disclosures of your protected health informationProtected Health Information. This means that you may ask us not to use or disclose any part of your protected health information Protected Health Information for the purposes of treatment, payment payment, or healthcare health care operations. You may also request that any part of your protected health information Protected Health Information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practicescare. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician [Club Physician, P.C.] is not required to agree to such a restriction that you may requestrestriction. If physician believes it is in we do agree, we will abide by your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right restriction unless we need to use another Healthcare Professionalyour Protected Health Information to provide emergency treatment. In addition, we may elect to terminate the restriction at any time. You have the right to request to receive confidential communications information from us by an alternative means or at an alternative locationlocation if you believe it would enhance your privacy. For example, you may request that we send written communications to an alternative address. We will attempt to accommodate all reasonable requests, and will not request an explanation from you as to the basis for your request. You have the right to inspect and copy your Protected Health Information. If you would like to see or copy your Protected Health Information, we are required to provide you access to your Protected Health Information for inspection and copying within 30 days after receipt of your request (60 days if the information is stored off-site). We may charge you a reasonable fee to cover duplicating costs. In addition, there may be situations where we may decide to deny your request if we believe the disclosure will endanger your life or health, request an amendment of your Protected Health Information in our records for as long as we maintain this information. We will respond to your request within 60 days (with up to a 30-day extension, if needed). We may deny your request if, for example, we determine that your Protected Health Information is accurate and complete. If we deny your request, we will send you a written explanation and allow you to submit a written statement of disagreement. You have the right to receive an accounting of certain disclosures we have made of your Protected Health Information. An accounting is a record of the disclosures that have been made of Protected Health Information. This right generally applies to non-routine disclosures, i.e., for purposes other than treatment, payment, or health care operations as described in this Notice, made in the six-year period prior to your request (although you are free to request an accounting for a shorter period). We are required to provide the accounting within 60 days (with one 30-day extension, if needed) and to provide one accounting free of charge in any 12-month period (for more frequent requests, a reasonable fee may be charged). You have the right to obtain a paper copy of this notice from us[Club Physician, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx XxxP.C.] ., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: 2006 Arena Football
Your Rights. Following is a statement of your rights with the respect to your protected health information. You have the right to inspect Inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; following: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purposes purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Health care Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon . Upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 1423, 2003. 0000 XX Xxxxxxx 00 XWe are required by law to maintain the privacy of, Xxxxxxxand provide individuals with, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwythis notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing please ask to speak with our HIPPA Compliance Officer in person or by the phone at our Main Phone Number. Signature below is only acknowledgement that you have received this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of our Privacy Practice - Disclosures of Protected Health Information Practices: Print Name:Name Signature
Appears in 1 contract
Samples: Hippa Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. J:\SHARED\Website Forms\HIPAA_2022.01.10.docx 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 0000 X XxXxxxxx Xxxxx Xx., A-1, Clearwater, FL 33761 (727) 788-3937 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. J:\SHARED\Website Forms\HIPAA_2022.01.10.docx 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 0000 X XxXxxxxx Xxxxx Xx., A-1, Clearwater, FL 33761 (727) 788-3937 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name: Signature: 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X Xxxxxxx Xxx, Xxxxx, XX 00000 (813) 908-2020 0000 X XxXxxxxx Xxxxx Xx., A-1, Clearwater, FL 33761 (727) 788-3937 xxx.XXXXXXXXX.xxx LASIK Screening Questionnaire Do you have trouble seeing far away or up close? How long has your prescription been stable? Do you wear contact lenses? Y N If YES, date last worn: What problems are you experiencing with your glasses and/or contacts? How long have you been thinking about having LASIK? What is your occupation? What are your hobbies? _ If you are a good candidate, how soon would you like to have the procedure? What (if anything) in the past has stopped you from proceeding with LASIK? Is there a chance you could be pregnant or nursing? Y N Are you planning to be pregnant within the next 6 months? Y N OCULAR HISTORY SYSTEMIC HISTORY Y N Keratoconus Y N Auto Immune Disorder Y N Corneal Erosions or Ulcers Y N Imitrex (sumatriptan) Use Y N Herpes Simplex Virus Keratitis Y N Cordarone (Amiodarone) Use Y N Lazy Eye Y N Accutane (Isotretinoin) Y N Dry Eyes Y N Diabetes Y N Thyroid Eye Disease Y N Psoriasis Y N Lid Disease Y N Eczema Y N Glaucoma Y N Organ Transplant Y N Macular Degeneration Y N Cataract Y N Retinal Tear or Detachment Y N Surgery or Injury to the Eye Y N Radiation Therapy Other:
Appears in 1 contract
Samples: Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect information and copy your protected health information. Under federal law, however, a brief description of how you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health informationexercise these rights. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy PracticesNotice. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician Citizens is not required to agree to a restriction that you may request. If physician Citizens believes it is in your best interest to permit use and disclosure of your protected health information, or that it is not reasonably feasible to comply with your request, your protected health information will not be restricted. If Citizens does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment as part of provision of your PERS services. You then have the right may request a restriction by submitting a written request to use another Healthcare ProfessionalCitizens. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests that are feasible to implement. We may also condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. You have the right make this request in writing to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronicallyCitizens. You may have the right to have your physician Citizens amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You may request an amendment by submitting a written request to Citizens. You have the right to receive an accounting of certain disclosures we have made, if any, of your personal and protected health information. We reserve the This right applies to change the terms disclosures for purposes other than provision of PERS services, treatment, payment or healthcare operations as described in this notice and will inform you by mail Notice of any changesPrivacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You then have the right to object or withdraw as provided in receive specific information regarding these disclosures that occurred after August 1, 2012. The right to receive this noticeinformation is subject to certain exceptions, restrictions and limitations. Complaints To request an accounting of disclosures, you may contact Citizens. You may complain have the right to us or to the Secretary obtain a paper copy of Health and Human Services this Notice from us, upon request, even if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA agreed to accept this Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxxelectronically., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: Service Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: Portal Agreement
Your Rights. Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; : psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. i.e., electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. J:\SHARED\Website Forms\HIPAA Notice of Privacy 09.05.18.docx This notice was published and becomes effective on/or before April 14, 2003. 0000 XX Xxxxxxx 00 X, Xxxxxxx, XX 00000 (863) 385-1544 00000 X Xxxx Xxxxx Hwy, Suite 200, Tampa, FL 33618 (813) 908-2020 000 X. Xxxxxxx Xxx., Xxxxx, XX 00000 (813) 908-2020 xxx.XXXXXXXXX.xxx Acknowledgement of Receipt By signing this document, I acknowledge that I have reviewed and/or requested a copy of the patient paperwork packet of Xxxxxx Eye. This packet includes the following: Please circle YES (Y) or NO (N) to applicable questions below. • Financial Policy – I have read and understand the Financial Policy and agree to meet all financial obligations. • Lifetime Authorization (1st & 2nd Sections) – Medicare or Insurance Certification for Payment. o Do you belong to a Health Maintenance Organization (HMO)? Y N o Do you need approval for your Primary Care Physician (PCP) before you can be seen by an ophthalmologist/optometrist? Y N • Do we have permission to: o Send a recall appointment reminder to your home Y N o Leave appointment, billing or treatment information on your voice mail, phone via text message or e-mail Y N o I give permission to share appointment, billing or treatment information with the person named below: Name: • Refraction(s) – I understand that a portion of my examination is not covered by Medicare/Most Insurance Plans and does not include this as of your integral exam (Refraction is $45.00) • Agreement as to Resolution of Concerns • HIPAA Notice of Privacy Practice - Disclosures of Protected Health Information Print Name:
Appears in 1 contract
Samples: covidtestinghuntingtonbeach.com
