NOTICE OF INFORMATION PRACTICES
- Piedmont Eye Center, Inc. may use and disclose protected health information for treatment, payment, and healthcare operations. Examples: referrals, nursing homes, pharmacies, hospital referrals, drug assistance programs, and low vision rehabilitation programs. Payment examples include: insurance companies and collection agencies. Healthcare operations include: electronic billing and auditing medical records.
- In certain circumstances under state and federal laws, Piedmont Eye Center, Inc. is required to disclose protected health information without the individual’s written consent or authorization. An example of such are for public health requirements or court orders.
- Piedmont Eye Center, Inc. will not make any other use or disclosure of a patient’s protected health information without the individual’s written authorization.
- Piedmont Eye Center, Inc. reserves the right to change the terms of its notice and to make new provisions effective for all protected health information that it maintains.
- Any patient, guardian or personal representative has the right to request, inspect and obtain copies of his/her medical record, request amendments be made to his/her medical record, request to receive confidential communications of protected health information by alternative means or at alternative locations, request a six-year accounting of all disclosures of his/her medical records and to request restriction as to how their health information may be used or disclosed to carry out treatment, payment or healthcare operations. The Practice is not required to agree to the restrictions requested except for a request for a restriction on a disclosure to a health plan where services have been paid in full, out-of-pocket; but if the Practice does agree, the Practice must abide by those restrictions.
- All such requests must be in writing and the practice must accommodate reasonable request.
- Any person/patient may file a complaint with the Practice and with the Secretary of Health and Human Services if he/she believes his/her privacy rights have been violated. No retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.
Effective date: 08/13/2013
YOUR FINANCIAL RESPONSIBILITY:
You are financially responsible for the services Piedmont Eye Center provides to you. We understand that many patients arrange for insurance companies to pay for a large portion of medical claims. However, the patient is ultimately responsible for the bill if the insurance company does not pay. We provide two billing related courtesies to our patients:
- We will contact your insurance carrier to request a pre-authorization/pre-determination for any planned treatments, if required by your insurer. It is important to understand that even if the insurance company provides authorization for treatment, it does not guarantee that they will pay once services have been performed. For this reason, we strongly recommend you contact your insurance company directly to confirm what degree of payment you can expect from them based on your individual plan, and to confirm that any planned procedures are included in the plan you chose.
- We will file a claim to your primary and secondary insurance plans. All payments are due at check-in.
Expect to pay at the date of service; co-payments, coinsurance, deductibles, non-covered services, and if Piedmont Eye Center does not participate with your insurance, if you have a Vision Plan, or if you are uninsured. If you are unsure of your financial responsibility, please contact your insurance company in advance, to obtain this information. We reserve the right to reschedule your appointment if your co-pay is not paid at check-in.
Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Any balance remaining after insurance has paid their part of the covered portion will be due prior to the next appointment.
Non-covered services
Most medical insurance plans, including Medicare & Medicaid, do not cover fees associated with routine refractions, completing medical forms, reproduction of medical records, cancelled appointments and no-shows. You must pay for these services in full. Refraction is performed to establish a baseline of the patient’s best corrected visual acuity in addition to determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of an eye examination for monitoring the health of the eye. Most medical insurance plans, including Medicare & Medicaid, do not cover routine refractions and allow that we charge separately for that portion of the examination, since it is not a covered service.
Missed appointments and no-shows
As a courtesy to our patients, we will call to remind you in advance of your upcoming appointment. Our staff will contact you at the telephone number you have provided 24-72 hours prior to your scheduled appointment. A fee of $40 will be assessed to your account if 24 hour advanced notice is not given. This fee is not covered by insurance carriers or Medicare and will be your responsibility to pay in full prior to scheduling your next appointment. A 24-hour notice of cancellation provides us with the ability to schedule patients on our wait list.
Changes to the Terms of this Notice
We reserve the right to change the terms of this notice, and the changes will apply to all information we have about you as well as future information. The new notice will be available upon request, in our office, and on our website. You have the right to a copy of this notice in paper form.
Sally Budd, Privacy Officer
Piedmont Eye Center
116 Nationwide Drive
Lynchburg, VA 24502
