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HIPAA Notice of Privacy Practices - Acknowledgement of Receipt

The privacy of your medical information is important, and we are committed to protecting it. To provide you with quality care and to meet federal legal requirements, we have created a record of the and services you have and will receive at Columbus Optical. If you would like a copy of the full-length Privacy Policy, please request it from the front desk.

Office Financial Policy

We are NOT on a billing system, and therefore, payment is expected at the time of service. If we agree to submit our billing to your third party payment carrier, we will do so in standardized format, to the best of our ability, and within two days of the services you receive. If we have NOT received payment by nine (9) weeks after your service date, we will expect that YOU are responsible for total payment of services rendered and pursuing your own reimbursement from your carrier. I hereby authorize payments of medical benefits to Patricia Hernacki, O.D. for any services rendered to me, and that I am responsible for any amounts not covered, as well as all co-payments, co-insurance fees, and applicable deductibles. I understand that I shall pay all attorney fees, court costs, and collection fees should they occur.
Due to the expense involved with issuing refunds, we no longer automatically return overpayments amounting to less than $15, but will hold these amounts as a credit balance in your name unless directed otherwise.

NOTICE OF PRIVACY PRACTICES - FEDERAL REQUIREMENT This notice takes effect of December 2002 and remains in effect until we replace it.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
The privacy of your medical information is personal and we are committed to protecting it. To provide you with quality care and to meet certain legal requirements we have created a record of the care and services you have received here.
OUR LEGAL DUTY REQUIRES US TO:
1) Keep your medical information private; 2) Give you this notice of our duties/practices and your rights regarding your medical information; 3) Follow the terms of the notice now in effect. We have the right to change our privacy practices and the terms at any time for even previously created medican information, provided the changes are permitted by law.
USE AND DISCLOSURE OF MEDICAL INFORMATION:
We will not use or disclose your medical information for any purpose not listed below without your written authorization. Any specific written authorization you provide may be revoked at any time by writing to us. We may typically disclose your medical information in order to carry out any treatment, appointment, payment, or health care operations. Less commonly, we will release in request by medical government organization (e.g. FDA, CDC, coroner, public health, etc.); to military personal and veterans; to national security and intelligence; to protective services (e.g. suspect, fugitive, material witness, crime victim, missing person, etc.); to correctional institutions and other law enforcement; to government programs providing public benefits; for court orders (e.g. subpoena, discovery request, warrant, grand jury, etc.); to workers compensation programs; to report blindess; or when necessary to prevent a serious threat to your health/safety or to the health/safety of others.
YOU ARE ENTITLED TO:
1) Look at or get copies of your medical information (photocopies at $3.50 per page, plus postage); 2) Receive a list of the times we have shared your medical information; 3) Request that we place additional restrictions on our disclosures or use of your medical information; 4) Request in writing that we change your medical information; 5) Request a paper copy of any electronic copy you have received; 6) Request confidential communications with you.
QUESTIONS OR COMPLAINTS:
Please contact Patricia Hernacki, O.D. or her office staff by mail at 2475 Cottage Ave., Columbus, IN 47201 or by phone at 812-372-7782. If you think that we may have violated your privacy rights, please contact the person named above and submit a written complaint to the U.S. Department of Health and Human Services. We can provide you with the address needed, and will not retaliate in any way if you choose to file a complaint.

NOTICE OF POSSIBLE INSURANCE/MEDICARE DENIAL
We will submit a copy of our charges to Medicare. We are a non-participating provider of services and do not typically accept assignment of benefits from Medicare except in some cases of foreign body removal, glaucoma treatment, cataract co-management, punctual occlusion, or photography. Medicare will only pay for services that it determines to be "Reasonable and Necessary" under section 1862(a)(1) of the Medicare Law. Therefore, it is possible that Medicare may deny payment for any service(s) that you receive. We will do our best to "code" your services so as to receive reimbursement, but this cannot be guaranteed. Your signature above authorizes us to release medical information to an insurer.