HIPAA, Financial Responsibility, & Billing Consent Form

In order for us to register you as a patient you will need to review and sign the notice of privacy practices (HIPAA), Financial Responsibility and Release for Medical Billing below. The Health Insurance Portability and Accountability Act (HIPAA) and Patient Privacy Statement
This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your Protected Health Information (PHI) to carry out Treatment, Payment or Health Care Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. Please review it carefully.
At Eye Care Specialists, P.C, we are committed to treating and using protected health information about you responsibly. This notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information.

This Notice of Privacy Practices describes how Eye Care Specialists P.C may use and disclose your PHI to carry out treatment, payment, and health care operations and for other purposes that are specified by law.
1 2 Eye Care Specialists P.C reserve the right to change this Notice. The changes will apply for PHI Eye Care Specialists P.C already have about you and PHI Eye Care Specialists P.C receive about you in the future. Eye Care Specialists P.C will provide an updated Notice to you when you request one. You may also obtain your own copy by calling our office at 781-769-8880.
If you have questions about this Notice, Eye Care Specialists P.C privacy practices, or Eye Care Specialists P.C that this Notice applies to, please contact Eye Care Specialists P.C at:

825 Washington Street Suite 230 Norwood, Ma 02062

Protected Health Information (PHI) is: Information about your physical or mental health, related health care services. Information that is provided by you, created by Eye Care Specialists by related organizations. Information that identifies you or could be used to identify you, such as demographic information, address and phone number, social security number, age, date of birth, dependents, and health history

Except as described in this Notice or specified by law, Eye Care Specialists will not use or disclose your PHI. Eye Care Specialists will use reasonable efforts to request, use, and disclose the minimum amount of PHI necessary. Whenever possible, Eye Care Specialists will de-identify or encrypt your personal information so that you cannot be personally identified. Eye Care Specialists have put physical, electronic, and procedural safeguards in place to protect your PHI and comply with federal and state laws.

You have the following rights with respect to your PHI.

You may obtain a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy.

You may ask Eye Care Specialists not to use or disclose any part of your PHI. Your request must be in writing and include what restriction(s) you want and to whom you want the restriction(s) to apply. Eye Care Specialists will review and grant reasonable requests, but Eye Care Specialists are not required to agree to any restrictions.

You have the right to inspect and get a copy of your PHI for as long as Eye Care Specialists maintain the information. You must put your request in writing. Eye Care Specialists may charge you for the costs of copying, mailing, or other supplies that are necessary to grant your request. If you would like an electronic copy of your health information, we will provide one to you as long as we can readily produce such information in the form requested. Eye Care Specialists have the right to deny your request to inspect and copy. If you are denied access, you may ask Eye Care Specialists to review the denial.

If you feel that your PHI is incomplete or incorrect, you may ask Eye Care Specialists to amend it. You may ask for an amendment for as long as Eye Care Specialists maintain the information. Your request must be in writing, and you must include a reason that supports your request. In certain cases, Eye Care Specialists may deny your request. If Eye Care Specialists deny your request for amendment, you have the right to file a statement of disagreement with Eye Care Specialists decision.

You have the right to receive a list of the disclosures (an accounting) that Eye Care Specialists has made of your PHI on or after April 14, 2003. The list will not include disclosures that Eye Care Specialists is not required to track, such as disclosures for the purposes of treatment, payment, or health care operations; disclosures which you have authorized Eye Care Specialists to make; disclosures made directly to you or to friends or family members involved in your care; or disclosures for notification purposes. Your right to receive a list of disclosures may also be subject to other exceptions, restrictions, and limitations.

Your request for an accounting must be made in writing and state the time period for which you would like Eye Care Specialists to list the disclosures. Eye Care Specialists will not include disclosures made more than six years prior to the date of your request, or disclosures made prior to April 14, 2003. You will not be charged for the first disclosure list that you request, but you may be charged for additional lists provided within the same 12-month period as the first.

You may ask Eye Care Specialists to communicate with you using alternative means or alternative locations. For example, you may ask Eye Care Specialists to contact you about medical records only in writing or at a different address than the one in your file. Your request must be made in writing and state how and when you would like to be contacted. You do not have to tell Eye Care Specialists why you are making the request, but Eye Care Specialists may require you to make special arrangements for payment or other communications. The payment fee for medical records is $25.00.

Eye Care Specialists will review and grant reasonable requests, but Eye Care Specialists are not required to agree to any restrictions. Note: Special Rules for Psychotherapy Notes. Only psychotherapy notes collected by a psychotherapist during a counseling session are considered PHI. If those notes are kept separate from a client's medical records, HIPAA requires that they be treated with higher standards or protection than other PHI. It is not Eye Care Specialists practice to keep psychotherapy notes as defined by HIPAA, or to keep any client notes separate from the client's file.

If you need to reschedule your appointment, please inform us at least 24 hours in advance. Failure to show up for a scheduled appointment will result in a $50 fee.

Our practice may use AI-assisted medical scribe technology to support clinical documentation during patient encounters. The AI scribe is used solely to assist healthcare providers in creating accurate and efficient medical records and does not replace the provider's clinical judgment or responsibility for the medical record. The use of AI scribe technology complies with all applicable patient privacy and confidentiality laws, including HIPAA. Any information processed by the AI scribe is handled using appropriate administrative, technical, and physical safeguards to protect patient privacy and the security of protected health information (PHI).

Common reasons for Eye Care Specialists use and disclosure of PHI include:

To provide, coordinate, or manage health care and related services for you to make sure you are receiving appropriate and effective care. For example, Eye Care Specialists may contact you to provide appointment reminders, information about treatment alternatives, or to refer you to other health-related benefits and services that may be of interest to you. Or Eye Care Specialists might contact another health care provider or third party to share information or consult with them about the services Eye Care Specialists is providing to you.

We may use and disclose your protected health information (PHI) to bill and receive payment for the healthcare services we provide. This includes submitting claims to your health insurance plan or other third-party payers on your behalf, verifying insurance eligibility and benefits, obtaining prior authorizations when required, and responding to requests for information related to payment of your claims. We will disclose only the information necessary to process your claims and receive payment, as permitted or required by applicable federal and state law, including the Health Insurance Portability and Accountability Act (HIPAA). The claims will be submitted either under Eye Care Specialists Tax ID or Norwood Eye Care Specialists Tax ID.

To assist in carrying out administrative, financial, legal, and quality improvement activities necessary to run Eye Care Specialists business and to support the core functions of treatment and payment.

We may disclose your health information to contractors, agents and other “business associates” who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, a billing company, an accounting firm, or a law firm that provides professional advice to us. Business associates are required by law to abide by the HIPAA regulations.

Eye Care Specialists may disclose PHI to a group health plan administrator, which may, in turn, disclose such PHI to the group health plan sponsor, solely for purposes of administering benefits.

Eye Care Specialists may disclose your PHI to a family member, other relative, close personal friend, or any person you identify, who is, based on your judgment, believed to be involved in your care or in payment related to your care. As required by law. Eye Care Specialists must disclose PHI when required to do so by law.

The following are less common reasons for the use and disclosure of PHI.

Eye Care Specialists may disclose PHI for a judicial or administrative proceeding in response to a court order, written notice, or protective order. To avert serious threats to public health or safety. Eye Care Specialists may disclose PHI to avoid a serious and imminent threat to your health or safety or to the health or safety of others. To provide reminders and benefits information to you.

Disclosures may be used to verify your eligibility for health care and enrollment in various health plans and to assist Eye Care Specialists in coordinating benefits for those who have other health insurance or eligibility for government benefit programs.

Eye Care Specialists may disclose PHI to comply with worker's compensation laws and other similarly legally established programs.

Eye Care Specialists may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse, neglect, or domestic violence.

Eye Care Specialists may use or disclose PHI to the Secretary of Health and Human Services to assist with a complaint investigation or compliance review.

Eye Care Specialists may disclose PHI to law enforcement officials for the purpose of identifying or locating a suspect, witness, or missing person, or to provide information about victims of crimes.

Eye Care Specialists are required to get your written permission (authorization) before using or disclosing your PHI for purposes other than those provided above, including use or disclosure of PHI for marketing purposes and sale of PHI, or as otherwise permitted or required by law. If you do not want to authorize a specific request for disclosure, you may refuse to do so without fear of reprisal.

If you do provide your written authorization and then later want to withdraw it, you may do so in writing at any time. As soon as Eye Care Specialists receive your written revocation, Red Lake Band of Chippewa Indian's Tribal Programs will stop using or disclosing the PHI specified in your original authorization, except to the extent that Eye Care Specialists has already used it based on your written permission.

If you believe your privacy rights have been violated, you can file a complaint with Eye Care Specialists HIPAA Privacy Officer, or with the United States Department of Health and Human Services at:
Medical Privacy Complaint Division
Office for Civil Rights
U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1-800-368-1019

Eye Care Specialists collects and uses information as described below.

Eye Care Specialists ask for information from you to determine what service or help you need, develop a service plan with you, and give you the services you want. The information may also be used to determine your charges for services or for collection of payment from insurance companies or other payment sources.

There is no law that says you must give Eye Care Specialists any information. However, if you choose to not give Eye Care Specialists some information, it can limit Eye Care Specialists ability to serve you well.

If you are here because of a court order, and you refuse to provide information, that refusal may be communicated to the Court. Without certain information, Eye Care Specialists may not be able to tell who should pay for your services.

If you are under 18, you may request that information about you be kept from your parents. You must give Eye Care Specialists your request in writing, describe the information, and tell Eye Care Specialists why you don't want your parents to see it. If, after reviewing your request, your physician at Eye Care Specialists believes that giving information to your parents is not in your best interest, Eye Care Specialists will not share the information. If your physician believes this information could be safely shared with your parents, Eye Care Specialists will inform you of that decision.

By signing this form your signature shows that Eye Care Specialists has informed you of your privacy rights, that you are aware of the possible uses and disclosures of your protected health information and that you have received a copy of this information.

I authorize Eye Care Specialists and its affiliates, its employees and agents, to exchange my personal health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me which identifies my name, address, Social Security number, member ID number) except the following information about me with any third-party payer having responsibility for payment of charges for treatment for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.

I understand that communication of the items can occur:
Verbally, In person conference, Written questionnaire, Mailed or faxed medical record/correspondence, Email.

My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Eye Care Specialists Privacy Notice. I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws.

I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Eye Care Specialists Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing. For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III).

Communications resulting from this authorization will reveal that I receive services at Eye Care Specialists.

Federal confidentiality regulations (at 42 CFR Part 2) prohibit re-disclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Eye Care Specialists to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules. This authorization may be used by Eye Care Specialists owned or managed programs upon transfer of my care to them.

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164).

I understand that by signing this form, I have read and I agree to the HIPAA Privacy Authorization Form and it will remain in effect for this and all future visits/treatments with Eye Care Specialists.

I understand that Eye Care Specialists may use the CORA AI medical scribe system during my visit to assist with clinical documentation. I understand that the AI system helps create visit notes for my provider, who will review and approve all documentation. I understand that my information is protected in accordance with HIPAA and applicable privacy laws.

Routine eye exam coverage is intended to cover the cost of an examination when there is no underlying medical issue.

Medical insurance covers expenses for eye exams that are considered medical in nature. Some examples of medical diagnoses include:

• Cataracts
• Dry eyes
• Floaters
• Eyelid styes
• Loss of vision
• Eye infection
• Glaucoma
• Diabetes

Routine eye exam coverage is typically included in vision insurance plans to help offset the costs associated with maintaining eye health. These exams are primarily designed to assess vision quality, update prescriptions for glasses or contact lenses, and screen for common eye issues. However, they focus on ensuring that no medical problems, such as glaucoma or macular degeneration, are present. If medical problems are suspected or detected during a routine exam, further diagnostic tests or treatments may fall under medical insurance rather than vision insurance. This distinction is important for understanding what your insurance plan will cover and ensuring you receive the appropriate care for your eye health needs.

Please call the number on the back of your insurance card if you have specific questions regarding your coverage.

I understand that by signing this form, I have read and I agree to Norwood Eye Care Specialists. Patient Financial Policy. By signing this form, I understand I am responsible only for the copayment, deductible, coinsurance, noncovered services, and any patient responsibility. I understand that by signing this form, it will remain in effect for this and all future visits/treatments with Norwood Eye Care Specialists.

Patient Information

Authorization for Release of Protected Health Information Form

I understand Eye Care Specialists P.C.'s policy regarding sharing my protected health information (PHI). I understand that state and federal laws permit Eye Care Specialists P.C. to share information about me, including details of the healthcare services I receive, with family and friends involved in my care or the payment of my healthcare services. I understand that, per my request, this authorization will permit the named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that I may revoke this authorization at any time by providing written notification to Eye Care Specialists P.C. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that I do not have to sign this authorization in order to receive treatment, payment, or to enroll or be eligible for benefits. If I do not specify an expiration date or event, this authorization will never expire on which I signed this authorization. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPAA’s privacy rules after the authorized disclosure. I also understand that listing individuals below does not grant them direct access to or copies of my medical records. This section is solely for identifying individuals who may contact Eye Care Specialists P.C. to obtain confidential information (PHI) and for your practice to communicate with about my care. Examples of such individuals include a spouse, children, parents, friends, etc. Per office policy, I understand that I may be charged a $25.00 fee based on the amount of records requested. Unless I request in writing otherwise, I understand that this authorization will expire on

1) Individual's Full Name

2) Individual's Full Name

3) Individual's Full Name

I, the above-named Releasor, hereby authorize the release of:

Do you permit Eye Care Specialists P.C to leave a detailed message on your answering machine/voicemail?

Emergency Contact

Insured Policy Holder Name

Financially Responsible Party

Appointments

Preferred Pharmacy

I consent to receive medical care and treatment from Eye Care Specialists and its providers. I authorize Eye Care Specialists to bill my insurance for services provided and assign payment of benefits directly to the practice. I understand that I am responsible for any costs not covered by my insurance, including copayments, deductibles, or non-covered services.