REGARDING VISION PLAN & MEDICAL INSURANCE

Transcription

1 REGARDING VISION PLAN & MEDICAL INSURANCE We often have patients that have both a vision plan (for example, VSP or EyeMed) and a medical insurance (for example, Cigna, Anthem, Humana, Aetna, United Healthcare, or Medicare). They are very different in terms of the services they cover, and it's important for our patients to understand these differences. A vision plan is designed mainly to cover determining a prescription for glasses and contact lenses, to help pay for glasses or contact lenses, and to cover a yearly wellness evaluation of the health of the eyes in a healthy patient that has no particular problems or symptoms. Vision plans are not equipped to deal with and do not cover medical conditions, injuries, and/or treatments. Medical insurance is designed to cover you when you have a medical problem, including one that affects your eyes. Medical insurance does not cover routine services or examinations for glasses, or routine vision problems such as nearsightedness, farsightedness, and astigmatism. Those are only covered by your vision insurance. When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as macular degeneration, an infection (pink eye), dry eyes, allergy, or cataracts, again, just to name a few, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply. Your vision plan does not cover these kinds of problems. Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them. There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with. We make every effort to join as many insurance panels, both medical and vision, as we can for your convenience. If we are on your insurance company's panel we will file those claims for you. In the event that we do not accept your medical or vision insurance we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance company yourself. If you have any questions, please let us know. I understand the information I've just read about the difference between vision and medical insurance. I authorize Philip Wren, O.D. to file my claim with the appropriate insurance based on the reason for my visit and the results of my examination. Signed: _ Date

2 Advanced Retinal Imaging With Optical Coherence Tomography OCT screening will safeguard your eye health. The health of your eyes matter to you and it matters to us too, which is why we are offering OCT to all our patients. OCT is a completely painless and highly advanced system that checks for potentially serious conditions such as glaucoma, diabetes, macular degeneration, and more. OCT scan in not covered by vision plan wellness examinations. Should you take advantage of the scan there will be a co-pay of $39 (usual fee is $55).

3 Optical Coherence Tomography (OCT) A whole new way of examining your eyes What is OCT? Optical Coherence Tomography uses low intensity infra-red light to give a 3D image of the back of the eye. It shows not only the surface but also the depth of the structures. It is similar to using ultrasound and creates an image not unlike an MRI or CT scan. The light levels are vey low, the scan takes seconds o acquire and is totally painless. All you need to do is look at a light, keep your eyes still and not blink for two seconds, simple as that! As well as the 3D scan, our instrument also takes a photograph of the eye in high resolution. This allows Dr. Wren to pin point any area of concern to review in depth. What are the benefits? The instrument is incredibly good at measuring and monitoring Macular Degeneration, Retinal Freckles, Glaucoma and many other Retinal Abnormalities. It can also mathematically show any changes from one visit to the next, working at a level way beyond the ability of even he most experienced observer with normal viewing methods. If there are any changes or abnormalities they can be monitored by Dr. Wren. Should a referral to a specialist be needed, the information Dr. Wren can provide can help immensely in aiding the specialist to prioritize the urgency for further assessment or treatment. Does everyone benefit? Everyone can have greater reassurance from a more in-depth examination. The two main areas where we see benefits are to people with, or likely to develop, Macular Degeneration and those with a family history of Glaucoma. Diabetes can be monitored and compared more accurately, which is beneficial in the long term. Do I need to have an OCT scan? When checking the health of our eye, the more information Dr. Wren has the better the quality of his decisions will be. This procedure gives Dr. Wren far more information to make a decision now, and improves his ability to compare and notice very subtle changes in the years to come. 3 ways to help protect and maintain a healthy macula: 1. Eat a diet rich in vitamins and minerals, particularly Lutein and Zeaxanthin. These are found in green leafy vegetables and in yellow fruits. 2. Have regular check-ups including the OCT scan to monitor any changes. 3. Protect your eyes against damaged from UV and Blue Light. When buying sunglasses make sure they have adequate UV protection.

4 GUNBARREL OPTOMETRY PATIENT REGISTRATION & MEDICAL HISTORY FORM First Name: Last Name: Preferred Name: Sex: M / F Birth Date: Social Security #: (Last 4 digits) _ Primary Insured s Name: Home Address: Zip: City: State: Which phone number would you prefer we use to contact you? Home Work Cell Home Phone: Work Phone: Cell Phone: Personal address: (We will not send you SPAM) Marital Status: Single Married Referred by: Family Members: For ease of data transfer, are they patients at this office? Y / N *We must have a copy of all insurance cards on the day of service Primary Medical Insurance: Vision Insurance: Insured s Birth Date: _ Family Doctor: Secondary Medical Insurance: Insured s Social Security #: (Last 4 Digits) Insured s Employer: Family Dr. Clinic/Phone: NOTICE OF PRIVACY PRACTICES: I/We have been offered a copy of Gunbarrel Optometry s statement on privacy practices AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Gunbarrel Optometry to release any medical or incidental information that may be necessary for medical benefit of in processing applications for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration, and Worker s Compensation. CONSENT FOR TREATMENT: I/We hereby authorize Gunbarrel Optometry to administer diagnostic and medical procedures as may be necessary for proper health care. OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, copay or any other balance not paid by my insurance company. I authorize insurance benefits to be paid directly to the provider. VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a later date. Due to changes in insurance regulations, if you have both a vision plan and a medical insurance plan, we are now required to coordinate your benefits with both plans. If you are being seen for a medical problem, or if you have any medical conditions that can affect the eyes or vision, your medical insurance will be billed first. Some of these medical conditions include: macular degeneration, diabetes, high blood pressure, blurred vision, glaucoma, flashes, floaters, rosacea, eye pain, itchy eyes, Bell s Palsy, double vision, allergies, foreign body, eye trauma, eye infection, eye injury, swollen eyelids, headaches, chalazion, dry eye, red eyes, stye, drooping eyelids, pink eye, burning eyes, shingles, etc. If you are here for a comprehensive, or annual examination, we must now submit the eyeglass prescription determination portion of the visit to your vision plan after submitting any medical claim to your medical insurance plan. You may still use vision plan materials benefits, if eligible, at the time of your exam. SIGNATURE: _ DATE: CHIEF COMPLAINT How can we help you today? In this space please check/explain any signs and/or symptoms you are experiencing. Medical insurance will only cover if there is a medical reason for the exam/test such as loss of vision, headaches, eye pain, eye itching or burning, redness, glaucoma, cataracts, floaters, dry eyes, etc. Blurred vision Floaters Eye pain/soreness Glare Dry eyes Loss of vision Crossed eyes Watery eyes Light sensitivity Red eyes Double vision Flashes of light Sandy/gritty feeling Tired eyes Burning/itching (explain): HISTORY OF PRESENT ILLNESS Location Which eye has the problem? Right Left Both Timing Is it new, ongoing, returning? New Ongoing Returning Quality How is it effecting you? Bothersome Aware Painful Context Associated w/: Infection Medical condition Injury Surgery Severity How severe is the problem? Mild Moderate Severe Modifiers Previous treatment? Drops Medication : Duration How long have you had the problem? Symptoms Are there associated symptoms? Headache : FAMILY HISTORY Has anyone in your family been diagnosed with any of the following (check all that apply): No problems Diabetes High blood pressure Cancer Glaucoma Amblyopia Cataracts Macular degeneration Strabismus (eye turn)

5 SOCIAL HISTORY Do you smoke? Do you consume alcohol? If yes, what do you smoke? Cigarettes Cigars Pipes If yes, how much do you drink? How much per month do you smoke? What is your occupation? CURRENT VISION CORRECTION Glasses: Do you currently wear glasses? if yes, answer the questions below; if no, continue to contact lenses section: What type of lenses are in your glasses? Single vision Bifocal Trifocal No-line (Progressive) Contact Lenses: Do you currently wear contact lenses? if yes, answer the questions below; if no, continue to past ocular history section: What type of contact lenses do you wear? Soft Rigid What is the brand of your contact lenses? What are the powers of your contact lenses (if you know)? How old are your current pair of contact lenses? Weeks / Months / Years How often do you replace your contact lenses? Daily Weekly 2 weeks Monthly 3 months 6 months Annually What solutions do you use to care for contact lenses? Renu Optifree Clear Care Boston RevitaLens : REVIEW OF SYSTEMS Ocular/Eye Problems Inflammatory disorder Surgery Glaucoma Amblyopia (lazy eye) Cataract Retinal problems Macular degeneration Strabismus (eye turn) Patching Constitutional Problems Cancer Fatigue Developmental disability Ears, Nose, Mouth, Throat Problems Laryngitis Dry mouth Hearing loss Sinusitis Neurological Problems Cerebral palsy Multiple sclerosis Tumor Epilepsy Psychiatric Problems Depression Cardiovascular Problems Vascular disease Stroke Congestive heart failure Heart disease High blood pressure Respiratory Problems Emphysema Bronchitis Smoker COPD Asthma Gastrointestinal Problems Colitis Crohn s disease Ulcer Genitourinary Problems Prostate disease/cancer STD Kidney disease Musculoskeletal Problems Ankylosising spondylitis Fibromyalgia Muscular dystrophy Osteoarthritis Skin Problems Rosacea Psoriasis Eczema Endocrine Problems Insulin dependent diabetes Non-Insulin diabetes Thyroid dysfunction Hormonal dysfunction Blood/Lymph Problems Large volume blood loss Anemia High Cholesterol Allergy/Immunologic Problems Environmental allergies Rheumatoid artheritis Drug allergies Lupus Do you sometimes experience dry eyes? Are your eyes sensitive to sunlight? Do you work at a computer? Problems with reflections and/or glare? Prefer not to wear your glasses at times? Interested in newer contact lens technology? Want information on thinner / lighter lenses? Want information on LASIK vision surgery? Want a non-surgical option to LASIK? Do you have any children? Do you spend time outdoors? Please list your sporting activities / hobbies: List any medications you are currently taking: List any medicine allergies: List any other allergies:

6 GUNBARREL OPTOMETRY CONTACT LENS POLICY If your appointment includes a contact lens fitting and evaluation, the following policy applies. I understand that contact lenses are medical devices and state law prohibits dispensing contacts after one year from the date of the examination. Disposable trial lenses are for fitting purposes only and will be dispensed at the initial fitting exam only. I understand that I should have a pair of glasses as a back-up to contact lenses. Contact lens prescriptions will be released to the patient after an assessment has been made by the doctor to deem an appropriate fit. I understand that not all contact lenses are designed for overnight wear and if I am fit with extended wear lenses, that I will follow the maximum extended wear recommendation. Contact lens examination fees, as with all other professional fees, are nonrefundable. Contact lens examinations include follow-up visits for 60 days after the initial fitting exam. It is the patient s responsibility to make sure that the follow-up is completed within the 60 day time period. If you fail to keep scheduled follow-up visits as recommended by the doctor during the 60 day period, additional office visit charges will apply. Any issues concerning the purchase or fees of the actual contact lenses are to be directed to the location where the contact lenses are purchased. Any medical eye conditions arising from contact lens wear will be billed as an office visit. X Date_ Signature of patient (or parent if a minor)

7 GUNBARREL OPTOMETRY 6545 Gunpark Dr. #250 Boulder, CO CONSENT FORM FOR eprescribe PROGRAM eprescribe Program eprescribing is way for doctors to send electronically an accurate, error free, and understandable prescription from the doctor s office to the pharmacy. The eprescribe Program also includes: Formulary and benefit transactions - Gives the health care provider information about which drugs are covered by your drug benefit plan. Fill status notification - Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled. Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy. The medication history information would include medications prescribed by Dr. Philip Wren as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information. Consent By signing this consent form you are agreeing that your Dr. Philip Wren may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it. This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to Dr. Philip Wren to enroll me in this eprescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction. Print Patient Name Signature of Patient or Guardian Patient DOB Today s Date Relationship to Patient

8 NOTICE OF PRIVACY PRACTICES Effective date of notice: 04/01/2015 Simple Optical, Inc. dba Gunbarrel Optometry 6545 Gunpark Dr., Ste. 250 Boulder, CO THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). Health care operations mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: When a state or federal law mandates that certain health information be reported for a specific purpose; For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; Uses or disclosures for health related research: Uses and disclosures to prevent a serious threat to health or safety; Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; Disclosures of de-identified information; Disclosures relating to worker s compensation programs; Disclosures of a limited data set for research, public health, or health care operations; Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; Disclosures to business associates who perform health care operations for us and who commit to respect the privacy of your health information; [Specify other uses and disclosures affected by state law]. Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care. APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written authorization form. The content of an authorization form is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations

9 must be in writing. Send them to the office contact person named at the beginning of this Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can: Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address or fax shown at the beginning of this Notice. Get a list of the disclosures that we have made of your health information within the past six years (or shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site. COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone. FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

10 ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Simple Optical, Inc., d.b.a. Gunbarrel Optometry make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I have read or had explained to me Gunbarrel Optometry s Notice of Privacy Practice and agree to continue my care with Gunbarrel Optometry under said terms. I was given to opportunity to read Gunbarrel Optometry s Notice of Privacy Practices and declined but wish to continue my care with Gunbarrel Optometry under the terms of Gunbarrel Optometry s privacy policies. I have read or had explained to me Gunbarrel Optometry s Notice of Privacy Practice and do not wish to continue my care with Gunbarrel Optometry under said terms. The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. _ Patient Date If you are signing as a personal representative of the patient, please indicate your relationship Representative Relationship to Patient