By attending for consultation or treatment, you agree to my terms and to pay any fees due to me for such consultation or treatment.
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1 Miss Louise E Allen MD FRCOphth Consultant Ophthalmic Surgeon Terms, Information about Fees and Privacy Notice for private patients May 2018 General By attending for consultation or treatment, you agree to my terms and to pay any fees due to me for such consultation or treatment. Following consultation or treatment I will send or give you an invoice for my professional fees. I require invoices to be settled within 30 days from the date of the invoice. Invoices settled beyond this period may incur an additional administrative charge of up to 50. My fees or charges may be paid in cash, by cheque or by bank transfer, or by credit or debit card. Credit or debit card payment can be taken over the phone, or I can you a link to make payment on request. If you are insured and have supplied your insurance details, the invoice for my services will, in most cases, be sent directly to your insurance company on your behalf, unless you request otherwise. Should I need to invoice you directly, payment will be required within 30 days, irrespective of whether you have received reimbursement from your insurance company. In all cases you will remain responsible for payment of my fees, including any excess or other amount which your insurance company declines to pay. You are strongly advised to confirm in advance with your insurance company that your consultation and any treatment required is covered and whether you have an excess on your policy. Services provided by other specialists working with me in my practice If I consider it advisable, and with your consent, you may also be seen by another practitioner, such as a registered orthoptist or contact lens fitter, who works with me in my practice. Orthoptists are registered practitioners who specialise in analysing eye movements and the way that the eyes work together. I consider this an important service for my patients who have disorders of ocular motility, and I work regularly with an experienced orthoptist, Mrs Anne Hitchcock. Mrs Hitchcock's services are provided by Cambridge Eye Diagnostic Centre Ltd, a group practice based at the Spire Cambridge Lea Hospital. Fees for orthoptic services provided by Cambridge Eye Diagnostic Centre Ltd will be charged by the hospital, which will provide further information on request. Louise Allen Consultant Ophthalmic Surgeon May 2018 page 1
2 Information on Fees I will send you details of the procedure code and description of the service(s) which I anticipate providing in advance, together with an estimate of my fees. I will also ask you to agree to these terms if you have not already done so. My Consultation Fees:..for an initial consultation (20300), will not exceed 205..for a follow up consultation (20310), will not exceed 145 These estimates are correct at the date these terms are sent to you or are downloaded from my web site. Fees for special tests or minor procedures carried out in the outpatient clinic: Before or after your consultation, you may need certain tests to help me diagnose your condition, such as blood tests or imaging. For example: a visual field test, biometry (eye measurements), special photographs, X-ray, MRI or CT scan. I may also advise that you have a minor procedure after your consultation, such as minor eyelid surgery or laser treatment. Such tests or procedures cannot always be anticipated, but if they are necessary I will explain the test or procedure and the reason for it, you will be advised of the fees and asked to sign your agreement. If you would like to know the charge for any particular test or procedure in advance, please ask. If a test is undertaken by the clinic or hospital, and not by me, the charge for those tests will be determined by the clinic or hospital and charged to you, or your private medical insurer, separately. If there are any fees which I will charge in relation to any of the tests I advise that you have, I will let you know what those will be. For minor procedures carried out in the outpatient clinic, I will advise you of my fee in advance. There will usually also be a charge made by the hospital for use of their facilities or equipment, such as the laser. This charge will be determined by the clinic or hospital and charged to you, or your private medical insurer, separately. Louise Allen Consultant Ophthalmic Surgeon May 2018 page 2
3 Fees for procedures carried out as a day patient or inpatient: I will send you details of the procedure code and description of the anticipated service(s), as above. Anaesthetist's fees, if applicable, are charged independently. The name and contact details of your anaesthetist will be provided on request. My fees for procedures and surgery are generally aligned with the benefits payable by most major UK insurance companies. However, this is not always the case and your insurance company may have its own scale of charges, which may differ. If there is a difference, you may be required to pay part or all of this. Other charges Should you cancel your appointment with less than 48 hours notice, a cancellation fee of up to 50% of the consultation fee may be charged. A fee may be charged for completion of claim forms, or for medical or other reports requested in addition to my normal clinic or post-operative letters. For claim forms the charge will be For reports, the fee will depend on complexity and time required and will be advised in advance if applicable. Private Medical Insurance If you have private medical insurance, please contact your insurer before your appointment, to check the terms of your policy, particularly the level and type of cover you have, including any reimbursement limits on individual consultation or surgical fees. I am recognised by the following private medical insurers: Allianz Partners Aviva AXA PPP Benenden Healthcare BUPA BUPA International CIGNA CS Healthcare The Exeter Healix health-on-line International SOS Multiplex Simplyhealth Tricare Universal Provident Vitality Health WPA Quality Information You can compare independent information about the quality of private treatment offered at the private hospitals and other private healthcare providers from the Private Healthcare Information Network (PHIN) website: Louise Allen Consultant Ophthalmic Surgeon May 2018 page 3
4 Using your personal data I am registered with the Information Commissioner s Office (registration number Z ) and have taken steps to ensure that my practice is compliant with the European General Data Protection Regulation [Regulation (EU) 2016/679] (GDPR). In accordance with the GDPR, I am required to provide you with this Privacy Notice, which sets out why and how I will collect, protect and use your personal data. In the context of this notice, references to actions by or responsibilities relating to myself will include those delegated to anyone working for me in my private practice. I (Louise Allen) am the data controller, and the legal bases under which I collect and process your personal data are: with your consent (requested below), for the purpose of providing you with medical consultation and treatment in accordance with our contract, and for the administration of my practice. The personal data that I collect and hold will include: your name, date of birth, address and other contact details; the names and contact details of your next of kin or responsible carer, and of other healthcare professionals or organisations connected with your care; your medical insurance details (if applicable); your medical record; information on charges made to you for my services, and payments from you or others in respect of those charges. I may collect this information directly from you, or it may be provided to me with your consent by another person or organisation, such as a healthcare professional, hospital or clinic, or insurance company. Your medical records are held on paper files, and administrative records and letters (including clinical letters) are held on computer. Your records will be archived to an entirely electronic format between one and five years after my last contact with you. I will ensure that all reasonable steps are taken to keep your records secure. This will include measures to ensure the protection of any personal data transferred outside the European Economic Area (EEA). Data which is transferred to the USA will be protected in accordance with the EU-U.S. Privacy Shield Framework. Your personal data will only be passed by me to medical personnel directly involved in your care or, for administrative purposes, to persons or organisations (such as hospitals, your insurance company, or government agencies) having a legitimate interest and under an obligation of confidence equivalent to that owed by health professionals. Otherwise, your personal data will only be passed to third parties with your consent, unless I am legally required to do so. If you have indicated that your treatment will be covered by insurance and your insurance company requests to know your diagnosis, this will be provided unless you request otherwise. More detailed clinical information will only be provided with your written consent. Louise Allen Consultant Ophthalmic Surgeon May 2018 page 4
5 You have the right to request that I correct inaccurate or incomplete information held about you. You have the right to withdraw or restrict your consent for me to collect and / or process your personal data at any time. If this affects my ability to provide you with an acceptable standard of care or to meet my professional obligation to you, I may have to advise you that I would no longer be able to manage your care. You have the right to obtain a copy of the records I hold about you on request. You also have the right to request erasure of your personal data. I will not keep your data for any longer than is necessary. However, to comply with medical best practice and for legal purposes, your personal data will normally only be destroyed a minimum of 8 years after the conclusion of treatment or your death. In the case of children who were aged 17 or under at the time of last contact, the record will not be destroyed until after their 26 th birthday. I may retain your personal data for a longer period if I believe that it may be required in defence of a claim that may be brought against me. Please note that, while I am able to accept payment by credit or debit card, I do not store any card details. When payment is taken over the phone, your card details are entered directly into the card payment company s secure web portal and are not recorded by me. If you provide an address, I may use this to send you appointment details, letters, and other information. Where these contain sensitive personal data or clinical information, the whole or the part containing personal data will be sent in an encrypted form. If you have any questions Please contact me by practice@louiseallen.com or write to me at: PO Box 1220 Duxford Cambridge CB22 4ZJ Louise Allen Consultant Ophthalmic Surgeon May 2018 page 5
6 Miss Louise E Allen MD FRCOphth Consultant Ophthalmic Surgeon Agreement to Terms Name of Patient... Date of Birth... Name of Person Signing (if different)... Relationship to Patient... Address I agree that you may collect and process my personal data for the purposes of providing medical consultation and treatment, and for the administration of your practice. YES NO I agree to these terms... (signature) Date... Louise Allen Consultant Ophthalmic Surgeon May 2018 page 6
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This is only a summary. The SBC shows you how you and the plan would share the cost for covered healthcare services. If you want more detail about your coverage and costs, you can get the complete terms
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/fi or by calling 1-800-542-9402.
Looking Upwards Value PPO Coverage Period: 04/01/ /31/2017
Important Questions What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling
Medical Plan Summary: PPO Core Plan
Medical Plan Summary: PPO Core Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation
ELECTRONIC FUNDS TRANSFER FORM (EFT) for Claim Payments
Claim Form This is the form to use when making a claim on any policy provided by AFA Pty Ltd, AFS Licence No 247122. Correct completion of these forms will assist us to make accurate and faster decisions
$1,500 Individual/$3,000 Family for In-Network providers.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-877-244-3593. HRA FUNDING
Drug Prior Authorization Form Pomalyst (pomalidomide)
This document contains both information and form fields. To read information, use the Down Arrow from a form field. Drug Prior Authorization Form The purpose of this form is to obtain information required
Equine Claim Form. Important Notes. Supporting Documentation
Equine Claim Form This form can be used to submit a claim under the following benefits: Veterinary Fees Death Permanent Loss of Use If you are submitting a new claim: Complete sections 1-5 and pass the
Guidance Notes For Medical Expenses Claims
Guidance Notes For Medical Expenses Claims Please submit originals of the following (photocopies are not acceptable, but we would suggest that you may wish to keep a copy for your own records): The Insurance
: POS HD 3000 Silver Coverage Period: 2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: POS
Standard Silver Point-of-Service This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.connecticare.com or
Anthem Blue Cross: Anthem Silver DirectAccess, a Multi-State Plan Coverage Period: 01/01/ /31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-855-333-5730. Important
$1,000 individual innetwork/$2,000. $1,000 individual out-ofnetwork/$2,000. family innetwork
Group Health Options, Inc.: Options Basic Plan Coverage Period: 7/1/2012 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Group Conversion Plan Type: POS This
Important Questions Answers Why this Matters:
This is only a summary. Medical benefits are covered through Anthem Blue Cross and Blue Shield. If you want more detail about your coverage and costs for health benefits, you can get the complete terms