HIPAA Compliance Patient Consent
Our Notice of Privacy Practices provides information about how we may use or disclose protected health
information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your
e-signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment
or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this
agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the
information for treatment, payment, or healthcare operations.
By my e-signature form, you consent to our use and disclosure of your protected healthcare information and
potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you.
However, such a revocation will not be retroactive.
By my e-signature, I understand that:
• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.
Financial Policy & General Consent
CONSENT TO TREATMENT:
By my e-signature, I do hereby voluntarily consent to treatment by the doctor of the
prac:ce for an eye exam and to any related diagnos:c procedures and treatments as necessary
in the judgement of the doctor. I acknowledge that eye exams are not always rou:ne in nature,
and at the discreton of my doctor, my medical insurance will be billed accordingly.
INSURANCE BILLING POLICY:
By my e-signature, I understand that Eye See Optique (an Eye Rx Partner) will bill my insurance on my behalf to carriers
which they are providers for. I understand that the prac:ce cannot guarantee anything
regarding my insurance, as it is a contract between me and the insurance company, not with the
office. The office will do it’s best to provide as much informa:on as possible, but I understand it
is my responsibility to know my insurance and benefits. I understand it is my responsibility to
obtain any referrals or prior authoriza:ons as necessary, and I am responsible for any balances
owed due to a lack of referral or prior authoriza:on. I also acknowledge that the office is not
responsible for filing a claim after the fact, if I did not present my insurance at the :me of the
appointment for any reason.
CONTACT LENS POLICY:
By my signature below, I understand that contact lenses are a separate service from an eye
exam, and I agree to pay any fees associated with obtaining a contact lens prescrip:on. I
acknowledge that contact lens prescrip:ons expire annually, in compliance with local state law,
and if I choose not to update my prescripton, I will not be able to order contact lenses in the
future.
FINCANCIAL POLICY:
By my e-signature, I understand that payment for all services is expected at the :me of
service. I understand that full payment is required for all eyewear and contact lens orders
before the order can be placed or dispensed.
