6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az

Transcription

1 Eye Physicians & Surgeons of Arizona 6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az George R. Reiss, MD Shamil S. Patel, MD Vinay M. Dewan, MD Christina M. Sorenson, OD Shenita Freeney, OD WE WILL NEED: *PHOTO ID *INSURANCE CARD *LIST OF MEDICATIONS (IF ANY) *Please make sure to complete all referring doctor and primary Doctor information. Including first and last name. *Please be prepared to be in the office for 2-3 hours for your Full evaluation, dilation and any testing. We greatly appreciate your patience! *PLEASE BE SURE ALL IS COMPLETE BEFORE GIVING PAPERWORK TO RECEPTIONIST*

2 Eye Physicians & Surgeons of Arizona REGISTRATION FORM Marital status (circle one) Single / Mar / Div / Sep / Wid Patient s last name: First: Middle: Home #: Cell #: Alt. #: Birth date: - - Street Address / P.O. Box: Social Security no.: City: State: Zip: address: Occupation: Employer: Employer phone no.: Referred here by: PLEASE BE SURE TO COMPLETE THIS SECTION Primary / Family Dr.: Referring Dr.: Phone #: Phone #: IN CASE OF EMERGENCY Name of local friend or relative: Relationship to patient Home phone No.: / Work phone No.: HIPAA IMPLEMENTATION PROCEDURES I understand that HIPAA has implemented procedures that require specific authorization for release of my information. I agree to the following statements and understand that I can revoke these at any time, by informing the Privacy Officer in writing: *A message may be left with a callback number or appointment reminder on my home, work or cell phone number. *Postcards may be sent to my home address or an , will be used for communication from this office and will not be shared with any other entity and give my permission for its use for this purpose. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Eye Physicians & Surgeons Of Arizona or insurance co. to release any information required to process my claims. Signature: Date

3 George R. Reiss, MD Shamil S. Patel, MD Christina M. Sorenson, OD Medical Insurance Patient name: Patient date of birth: Patient Insurance name: BCBS AHCCCS: Medicare with Supplement Banner health Aetna Medicare Complete UHC AARP Cigna Tricare Coventry Ameriben Solutions Administrative Options United Health Care Az. Foundation for Medical care GEHA Beach Street Gilsbar Champ VA Health Net Great West GHI Mail handlers benefit UMR Indian health Services / Contract Health Other Patient insurance ID number: Policy holder name (if different from patient spouse ): Policy holder date of birth: **PLEASE MAKE SURE YOU GIVE US YOUR CARD/S, SO THAT WE CAN MAKE A COPY FOR OUR RECORDS**

4 Eye Physicians & Surgeons of Arizona Signature on File, Assignment of Benefits, Financial Agreement, HIPAA Notice MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Eye Physicians & Surgeons of Arizona for services furnished me by Dr. Reiss, Dr. Patel, Dr. Dewan, Dr. Sorenson or Dr. Freeney. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and it s agents and information needed to determine these benefits or benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA 1500 form, my signature authorizes releasing the information to the insurer or agency shown. Dr. Reiss, Dr. Patel, Dr. Dewan, Dr. Sorenson or Dr. Freeney accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in the item of the HCFA 1500 form, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Eye Physicians & Surgeons of Arizona, is possible or otherwise me. OTHER INSURANCE: As a courtesy, Eye Physicians & Surgeons of Arizona will bill all primary insurance coverage if he is a contracted provider. If they are not a contracted provider, I will pay for all services at the same time they are rendered. I authorize payment of my medical and surgical insurance benefits to Eye Physicians & Surgeons of Arizona. I understand I am financially responsible for any charges whether or not paid by my insurance. If co payment and/ or deductibles are designated by my insurance company or health plan, I agree to pay them to Eye Physicians & Surgeons of Arizona. I authorize Eye Physicians & Surgeons of Arizona to release any information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be in place of the original. NON-COVERED SERVICES: I understand that Eye Physicians & Surgeons of Arizona contract with health care services plans (i.e., HMO s, PPO s) relates only to items and services which are covered by the health care service plans. These procedures may include, but are not limited to refractions. A refraction may be preformed to verify whether or not my vision can be improved with a new prescription or whether surgery is indicated. A refraction is considered routine by Medicare and most other health care service plans. Accordingly, I accept full financial responsibility for all items or services, which are determined by the health care service plans not to be covered. FINANCIAL AGREEMENT: I agree that in return for the services provided to me by Eye Physicians & Surgeons of Arizona, I will pay my account, including co-pay, deductible, and non-covered fees at the time service is rendered. If my account is sent to an agency for collection, I agree to pay collection expenses and reasonable attorney s fees as established by the court and not pay a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance are hereby assigned to Eye Physicians & Surgeons of Arizona. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Eye Physicians & Surgeons of Arizona. However, I understand that I am primarily responsible for the payment of my bill. CO-PAYS AND NON-COVERED FEES ARE DUE AT TIME OF SERVICE! PLEASE BE AWARE MEDICAL INSURANCE WILL NOT COVER A PRESCRIPTION FOR GLASSES! A $50.00 FEE IS DUE AT TIME OF SERVICE, this service is NOT part of our exam you will need to REQUEST the technician to do this exam if needed. X Date Signature of Beneficiary or Authorized Party

5 Eye Physicians & Surgeons of Arizona PERSONAL REPRESENTATIVE AUTHORIZATION FOR MEDICAL RELEASE FORM (PLEASE READ CAREFULLY & COMPLETE ALL SECTIONS) The information below can only be released to the following persons (Family Members, Personal Representative, etc., NOT INCLUDING DOCTORS): PRINT NAME/S RELATIONSHIP **Please check here if you DO NOT authorize anyone to have access or to discuss your account or medical information.** All medical information, including but not limited to records pertaining to examination, treatments, consultations, billing records, x-rays and reports, treatment records, diagnosis and prognosis and records, nurse s and doctor s notes and any other non-medical information in my file. Only the following types of information: I understand that I may terminate this Medical Authorization form. I must notify this facility in writing regarding termination and effective date. Until revoked in writing. I know that I am entitled to receive a copy of this agreement. Name: Signature: Signed Date:

6 Eye Physicians & Surgeons of Arizona TO OUR PATIENTS IMPORTANT PAYMENT INFORMATION ABOUT NON-Covered/ OUT OF POCKET SERVICES Refraction is the process of determining the eye s refractive error, or need for corrective lenses. However, it is considered a non-covered service by Medicare and most insurance companies; thus, it becomes the responsibility of the patient to pay for the refraction portion of the examination if you choose to purchase one. If you are interested in a prescription for glasses our fee for the refraction is $50, and is collected at the time of your visit, in addition of any co-payments or deductible due for the medical portion of your examination. I accept full financial responsibility for the cost of this service. Please notify your servicing technician if you would like a refraction (This is NOT a mandatory service) Disability/FMLA Forms: There will be a $25.00 fee for the completion and processing of all disability and FMLA related paperwork. Please also allow5-7 business days for these to be completed. AZDOT MVD forms: Fee $60 for completion and service By signing my name below, I certify that I have read the above information. Any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the above policies. I understand I am responsible for all charges not paid by insurance. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request. (Signature is required) Print Name Patient Signature or Parent for Minor Date:

7 SUMMARY OF PRIVACY PRACTICES This summary of our privacy practices is contains a condensed version of our Notice of Privacy Practices. Our full-length Notice follows this summary. Date of Last Revision May 12, 2013 Effective Date: Immediately THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DIS- CLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CARE- FULLY. We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private. How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices that follows this summary): 0) For medical treatment 1) For research 2) To obtain payment for our services 3) To avert a serious threat to health or safety 4) In emergency situations 5) For organ and tissue donation 6) For appointment and patient recall reminders 7) For workers' compensation programs 8) To run our Practice more efficiently and ensure all our patients receive quality care 0) In response to certain requests arising out of lawsuits or other disputes If you believe your privacy rights have been violated, you may file a complaint with Eye Physicians & Surgeons of Arizona or with the Secretary of the Department of Health and Human Services. To file a complaint with Eye Physicians & Surgeons of Arizona, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You have certain rights regarding the information we maintain about you. These rights include: 0) The right to inspect and copy 1) The right to request restrictions 2) The right to amend 3) The right to a paper copy of this notice 4) The right to an accounting of disclosures 5) The right to request confidential communications

8 For more information about these rights, please see the detailed Notice of Privacy Practices that follows this summary. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE READ IT CAREFULLY The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your personal health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation. Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would include referring you to a specialist. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery. Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards. The practice may also disclose your PHI for law enforcement and other legitimate reasons although we shall do our best to assure its continued confidentiality to the extent possible. We may also create and distribute de-identified health information by removing all reference to individually identifiable information. We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving fundraising communications from us.

9 The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you: Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations; Disclosures that constitute a sale of PHI under HIPAA; and Other uses and disclosures not described in this notice. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You may have the following rights with respect to your PHI. The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of Protected Health Information by alterative means or at alternative locations. The right to inspect and copy your PHI. The right to amend your PHI. The right to receive an accounting of disclosures of your PHI. The right to obtain a paper copy of this notice from us upon request. The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed. If you have paid for services "out of pocket", in full, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure. We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal duties and our privacy practice with respect to PHI. This notice if effective as of April 14, 2003 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practice from our office. You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with office and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint. Feel free to contact our Compliance Officer for more information, in person or in writing.

10 WRITTEN ACKNOWLEDGEMENT FORM I am a patient of Eye Physicians & Surgeons of Arizona I hereby acknowledge receipt of Eye Physicians & Surgeons of Arizona Notice of Privacy Practices. Name [please print]: Signature: Date: OR (for MINORS under 18) sign below I am a parent or legal guardian of [patient name] I hereby acknowledge receipt of 's Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: Parent Legal Guardian Signature: Date:

11 **PLEASE FAX THIS FORM BACK WITH RECORDS** CONFIDENTIAL Authorization for Disclosure of Protected Health Information (Medical Records Release) Received in office by: Date: In order to provide for your healthcare, our practice collects information about your medical history, physical examinations, test results, diagnoses and treatments. Use and disclosure of protected health information is regulated by a federal law known as The health Insurance Portability and Accountability Act of 1996 ( HIPAA ). Under HIPAA, healthcare providers must obtain a valid authorization in order to release any such information to a third party for purposes non related to your treatment, receiving payment, or healthcare operations. This authorization gives our practice permission to disclose the elements of your protected health information listed below for the specified purposes to the stated recipient. I understand that I do not have to sign this authorization to get health care benefits (treatment, payment or enrollment), Except: to take part in research study; or to receive health care when the purpose is to create health information for a third party. I understand that I may revoke this authorization in writing at any time. However, I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of health information or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest the claim. Patient Address (print) D.O.B. Therefore I, (sign) consent to the disclosure of the following: MRI Office notes Lab reports Fundus photos All clinical record Visual fields Other (specify) List other facilities records to be included when releasing for the purpose of continuing medical care: Release from: (name of doctor): Phone / Fax # Release to: At the request of the individual Further medical care Eye Physicians & Surgeons Of Arizona *6677 W. Thunderbird F-101, Glendale, Az *10603 N. Hayden H-100, Scottsdale, Az Ph Fax back to: Record copied by: Faxed or mailed by: Date:

12 Medications List PATIENT NAME: DATE: MEDICATION / MILIGRAMS / MILLILITERS FREQUENCY REASON FOR MEDICATION