NEW PATIENT PACKET (English)
To receive forms in Spanish, please call or text 707.252.2020.
Thank you for choosing us as your specialty health care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.
We participate in most insurance plans, including Medicare. If you are not insured by a health insurance plan that we do business with, payment in full is expected at each visit. If you are insured by a health insurance plan that we do business with but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
Co-payments and deductibles.
All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit
Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. A refraction is not covered by most medical insurances.
Proof of insurance.
All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request.
Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.
Our policy is to charge Forty Dollars ($40.00) for missed appointments not canceled within a reasonable amount of time (24 hours in advance). These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.
Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.
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 understand that your health information is personal to you, and we are committed to protecting the information about you. This Notice of Privacy Practices (or “Notice”) describes how we will use and disclose protected information and data that we receive or create related to your health care.
We are required by law to maintain the privacy of your health information, and to give you this Notice describing our legal duties and privacy practices. We are also required to follow the terms of the Notice currently in effect.
How We May Use And Disclose Health Information About You
We will not use or disclose your health information without your authorization, except in the following situations:
Treatment: We will use and disclose your health information while providing, coordinating or managing your health care. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will put in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We may also provide other health- care providers with your information to assist him or her in treating you.
Payment: We will use and disclose your medical information to obtain or provide compensation or reimbursement for providing your health care. For example, we may send a bill to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. As another example, we may disclose information about you to your health plan so that the health plan may determine your eligibility for payment for certain benefits.
Health Care Operations: We will use and disclose your health information to deal with certain administrative aspects of your health care, and to manage our business more efficiently. For example, members of our medical staff may use information in your health record to assess the quality of care and outcomes in your case and others like it. This information will then be used in an effort to improve the quality and effectiveness of the healthcare and services we provide.
Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associate so they can perform the job we’ve asked them to do. However, we require the business associate to take precautions to protect your health information.
Facility Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, [and religious affiliation] for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. Notification of Family: We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your location and general condition.
Communication With Family: We may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care.
Research: Consistent with applicable law we may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Funeral Director, Coroner, and Medical Examiner: Consistent with applicable law we may disclose health information to funeral directors, coroners, and medical examiners to help them carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may dis- close health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Fundraising: We may use certain information for purposes of raising funds.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events, product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, including child abuse and neglect.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
Health Oversight: In order to oversee the health care system, government bene- fits programs, entities subject to governmental regulation and civil rights laws for which health information is necessary to determine compliance, we may disclose your health information for oversight activities authorized by law, such as audits and civil, administrative, or criminal investigations.
Court Proceeding: We may disclose your health information in response to requests made during judicial and administrative proceedings, such as court orders or subpoenas.
Law Enforcement: Under certain circumstances, we may disclose your health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concern- ing identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Threats to Public Health or Safety: We may disclose or use health information when it is our good faith belief, consistent with ethical and legal standards, that it is necessary to prevent or lessen a serious and imminent threat or is necessary to identify or apprehend an individual.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
Other Uses: We may also use and disclose your personal health information for the following purposes:
- To contact you to remind you of an appointment for treatment;
- To describe or recommend treatment alternatives to you;
- To furnish information about health-related benefits and services that may be of interest to you; or
- For certain charitable fundraising purposes.
Prohibition on Other Uses or Disclosures
We may not make any other use or disclosure of your personal health information without your written authorization. Once given, you may revoke the authorization by writing to the contact person listed below. Understandably, we are unable to take back any disclosure we have already made with your permission.
You have many rights concerning the confidentiality of your health information. You have the right:
- To request restrictions on the health information we may use and disclose for treatment, payment, and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to the address below.
- To receive confidential communications of health information about you in a certain manner or at a certain location. For instance, you may request that we only contact you at work or by mail. To make such a request, you must write to us at the address below, and tell us how or where you wish to be contacted.
- To inspect or copy your health information. You must submit your request in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies.
In certain circumstances we may deny your request to inspect or copy your health information. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional will then review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if:
- The information was not created by us, unless the person that created the information is no longer available to make the amendment,
- The information is not part of the health information kept by or for us,
- Is not part of the information you would be permitted to inspect or copy, or
- Is accurate and complete
- To receive an accounting of disclosures of your health information. You must submit a request in writing to the address below. Not all health information is subject to this request. Your request must state a time period, no longer than 6 years and may not include dates before April 14, 2003. Our request must state how you would like to receive the report (paper, electronically). The first accounting you request within a 12-month period is free. For additional accountings, we may charge you the cost of providing the accounting. We will notify you of this cost and you may choose to withdraw or modify your request before charges are incurred.
- To receive a paper copy of this Notice upon request, even if you have agreed to receive the Notice electronically. You must submit a request for a paper notice in writing to the address below.
All requests to restrict use of your health information for treatment, payment, and health care operations, to inspect and copy health information, to amend your health information, or to receive an accounting of disclosures of health information must be made in writing to the contact person listed below.
If you believe that your privacy rights have been violated, a complaint may be made to our privacy officer at the address listed below. You may also submit a complaint to the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Eye Care Center of Napa Valley
895 Trancas Street
Napa, CA 94558
Changes to This Notice
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility.
Notice Effective Date: April 1, 2003