CONSENT OF TREATMENT, BILLING, AND NOTICE OF PRIVACY PRACTICES
WINK EYECARE BOUTIQUE,LLC
1095 Seven Locks Rd, Potomac, MD 20854
I, the undersigned, authorize Wink Eyecare Boutique, LLC to release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such eye care to third party payers and other health practitioners involved in my care. I authorize and request my insurance company to pay directly to Wink Eyecare Boutique, LLC all insurance benefits otherwise payable to me for services rendered. I understand that my eye care or medical insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Service charges of 1 1/2 % per month will be added to all balances over 60 days past due. In the event it becomes necessary to collect a balance through litigation or a collection agency, I agree to pay all collection fees, and attorney’s fees incurred. I further authorize the use of this signature on all insurance submissions
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
We are committed to maintaining the privacy of your protected health information (“PHI”). We are legally required to record information about your health condition and the care and treatment you receive here, and this record-keeping is critical to your safety. This Notice details how your PHI may be used and disclosed to third parties. It also reviews your rights regarding your PHI.
Our records are electronic and can be accessed only by the doctor and staff via password entry. We do not send records by email without encrypting them to prevent their being read by parties other than the intended recipient. You have the right to see the records that we keep about your care.
We may disclose your PHI to other parties, without a separate consent for its release, in the following situations: 1) to other doctors and health care providers who are already treating you with your consent, or to whom you are being referred as part of our explicit plans (you will know when this is going to occur); 2) to third party payors (e.g. Medicare or your insurance company) in order for you to receive the coverage benefits that pay for your care; 3) to various third parties who are monitoring the quality of the care you receive, as required by law; and 4) to our business associates such as billing services.
The Practice may also disclose your PHI, without a written Consent from you, in the following additional instances: 1) De-identified information that does not identify you and, even without your name, cannot be used to identify you; 2) To a business associate if we obtain satisfactory written assurance, that they will appropriately safeguard your PHI; 3) To a person who, under applicable law, has the authority to represent you in making decisions related to your health care; 4) for the purpose of obtaining or rendering emergency treatment; 5) To a government authority if the Practice is required by law to make such disclosure regarding physical abuse or neglect; 6) To agencies charged with Health Oversight Activities, as required by law, including criminal investigations; 7) In response to a court order or a lawfully issued subpoena; 8) to a law enforcement official under certain circumstances; 9) To a coroner or medical examiner for the purpose of identifying you or determining your cause of death; 10) To an entity to whom you have agreed to donate your organs; 11) To prevent or lessen a serious and imminent threat to the health or safety of a person or the public (to an individual who is reasonably able to prevent or lessen the threat); 12) To the Workers’ Compensation system.
X_______________________________________ Patient’s Date of Birth ________________
Signature of Patient or Parent
X_______________________________________ Date ______________________________
Printed Name of Patient or Parent
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