If you give us authorization to release your health information above, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

For under age 18, a parent, guardian or representative must consent. If you are signing as a representative of the patient, please indicate your relationship.

Millennium Eye Center Privacy/Security Official, James Justin
NOTICE OF PRIVACY PRACTICES - This notice was published and becomes effective on October 1, 2017
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.
YOUR RIGHTS
When it comes to your health
information, you have certain rights.
This section explains your rights and
some of our responsibilities to help you.
Get an electronic or paper copy of your
medical record:
• You can ask to see or get an
electronic or paper copy of your
medical record and other health
information we have about you.
• We will provide a copy or a
summary of your health
information, upon your request,
within 30 days. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record:
• You can ask us to correct health
information about you that you
think is incorrect or incomplete.
• We are allowed by law to say “no”
to your request, but we’ll tell you
why in writing within 60 days.
Request confidential communications:
• You can ask us to contact you in a
specific way (for example, home
or office phone) or to send mail to
a different address.
• We will say “yes” to all reasonable
requests.
Ask us to limit what we use or share:
• You can ask us not to use or
share certain health information
for treatment, payment, or our
operations.
• We are not required to agree to
your request, and we may say
“no” if it would affect your care.
• If you pay for a service or health
care item out-of-pocket in full, you
can ask us not to share that
information for the purpose of
payment or our operations with
your health insurer.
• We will say “yes” unless a law
requires us to share that
information.
Get a list of those with whom we’ve
shared information:
• You can ask for a list (accounting)
of the times we’ve shared your
health information for six years
prior to the date you ask, who we
shared it with, and why.
• We will include all the disclosures
except for those about treatment,
payment, and health care
operations, and certain other
disclosures (such as any you
asked us to make). We’ll provide
one accounting a year for free but
will charge a reasonable, costbased
fee if you ask for another
one within 12 months.
Get a copy of this privacy notice:
• You can ask for a paper copy of
this notice at any time, even if you
have agreed to receive the notice
electronically. We will provide you
with a paper copy promptly.
Choose someone to act for you:
• If you have given someone
medical power of attorney or if
someone is your legal guardian,
that person can exercise your
rights and make choices about
your health information.
• We will make sure that person
has this authority and can act for
you before we take any action.
File a complaint if you feel your rights
are violated:
• You can complain if you feel we
have violated your rights by
contacting us using the
information on page 1.
• You can file a complaint with the
U.S. Department of Health and
Human Services Office for Civil
Rights by sending a letter to 200
Independence Ave., S.W.,
Washington, D.C. 20201, or by
calling 1-877-696-6775, or by
visiting
www.hhs.gov/ocr/privacy/hipaa/co
mplaints/.
• We will not retaliate against you
for filing a complaint.
YOUR CHOICES:
For certain health information, you can
tell us your choices about what we
share. If you have a clear preference
for how we share your information in
the situations described below, talk to
us. Tell us what you want us to do, and
we will do our best to follow your
instructions.
In these cases, you have both the right
and choice to tell us to:
• Share information with your family,
close friends, or others involved in
your care.
• Share information in a disaster relief
situation.
• Contact you for fundraising efforts.
• If you are not able to tell us your
preference, for example if you are
unconscious, we may go ahead and
share your information if we believe
it is in your best interest. We may
also share your information when
needed to lessen a serious and
imminent threat to health or safety.
In these cases we NEVER share your
information UNLESS you give us
written permission:
• Marketing purposes.
• Sale of your information.
In the case of fundraising:
• We may contact you for fundraising
efforts, but you can tell us not to
contact you again.
OUR USES AND DISCLOSURES:
How do we typically use or share your
health information? We typically use or
share your health information in the
following ways.
Treat you:
• We can use your health
information and share it with other
professionals who are treating
you.
• For example, a doctor treating you
for an injury asks another doctor
about your overall health
condition.
Run our organization:
• We can use and share your health
information to run our practice,
improve your care, and contact
you when necessary.
• For example, we use health
information about you to manage
your treatment and services.
Bill for your services:
• We can use and share your health
information to bill and get payment
from health plans or other entities.
• For example, we give information
about you to your health insurance
plan so it will pay for your services.
How else can we use or share your
health information? We are allowed or
required to share your information in
other ways – usually in ways that
contribute to the public good, such as
public health and research. We have to
meet many conditions in the law before
we can share your information for these
purposes. For more information see
www.hhs.gov/ocr/privacy/hipaa/underst
anding/consumers/index.html .
Help with public health and safety
issues:
• We can share health information
about you for certain situations such
as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to
medications
• Reporting suspected abuse, neglect,
or domestic violence
• Preventing or reducing a serious
threat to anyone’s health or safety
Do Research:
• We can use or share your
information for health research.
Comply with the law.
• We will share information about you
if state or federal law requires it,
including with the Department of
Health and Human Services if it
wants to see that we’re complying
with federal privacy law.
Respond to organ and tissue donation
requests:
We can share health information about
you with organ procurement
organizations.
Work with a medical examiner or
funeral director:
We can share health information with a
coroner, medical examiner, or funeral
director when an individual dies.
Address workers’ compensation, law
enforcement, and other government
requests:
• We can use or share health
information about you:
• For workers’ compensation claims
• For law enforcement purposes or
with a law enforcement official
• With health oversight agencies for
activities authorized by law
• For special government functions
such as military, national security
and presidential protective services.
Respond to lawsuits and legal actions:
• We can share health information
about you in response to a court or
administrative order, or in response
to a subpoena.
• Our practice does not create or
manage a hospital directory, nor do
we have or maintain psychotherapy
notes at this practice.
• We adhere to all FLORIDA laws that
require greater limits on disclosures
than the federal HIPAA/HITECH
laws require.
OUR RESPONSIBILITIES:
We are required by law to maintain the
privacy and security of your protected
health information.
We will let you know promptly if a
breach occurs that may have
compromised the privacy or security of
your information.
We must follow the duties and privacy
practices described in this notice and
give you a copy of it.
We will not use or share your
information other than as described
here unless you tell us we can in
writing. If you tell us we can, you may
change your mind at any time. Let us
know in writing if you change your
mind.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understandin
g/consumers/noticepp.html .
CHANGES TO THE TERMS OF THIS
NOTICE:
We can change the terms of this notice at
any time, and the changes will apply to all
information we have about you. The new
notice will be available upon request, in our
office, and on our website.

A comprehensive Eye examination is not complete without a thorough retinal exam. In order to get a good view of the retina, the doctor use ophthalmic drops to dilate the pupils. Once the pupils are dilated, the doctor can thoroughly check for any eye diseases while examining the internal eye structures. Without dilating the pupils, the view of the Retina is limited and our doctor will not be able to detect any asymptomatic retinal conditions.

Pupil dilation can cause the following symptoms:

• Ocular numbness, sleepy or heavy eyes for about 20-30 minutes. Sensitivity to bright light such as the sun for up to six hours and sometimes 24 hours depending on the strength of the drops used.
• Objects positioned at arm length or closer may be blurry for a period of four to six hours or longer depending on the drops used.
• Very seldom patients with a history of migraine headaches may get an episode with pupil dilation… Please inform the staff and doctor about any such condition.
• Because children usually have excessively strong focusing systems, the doctor may use stronger drops to control the focusing system in order to insure an accurate prescription. In such cases, the side effects listed above will last for 18-24 hours depending on individual sensitivities. Parental consent for pupil dilation is required for children under 18.

Payment is expected at Time of Service

For all patients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time the service is rendered.

There will be a $5 billing fee charge to cover our administrative mailing costs if payment is not made at the time of service. Also, anyone submitting insurance paperwork after the original date of service will be charged a fee of $5.

You are responsible for any balances not covered by your insurance, including rejected claims. While every effort will be made to submit claims in accordance with insurers' requirements for payment, in the event of a dispute or rejection, you as the insured or guarantor are responsible for payment.

Insurance claims not paid within 90 days after the original date of service will become the responsibility of the patient/insured.

For the purpose of this agreement, “non covered charges” are charges otherwise billed, that are not covered by a third party for any reason. These charges may include, but are not limited to: denial of coverage, exclusion of coverage and absence of a responsible third party payer. However, “non covered charges” do not included differences between MEC charges and rates that have been established through contract, if applicable. Regardless of my status at the time I sign this agreement. Whether I am signing as an agent/representative or patient, I obligate myself to this agreement which states that payment of services rendered will be paid to MEC regardless of condition. I hereby guarantee payment of all applicable co- payments, deductibles, and charges not covered through benefits. In the event any portion of said patient’s account(s) are referred to an attorney for collection due to non payment, I agree to payment of all expenses pertaining to collection, including reasonable legal fees regardless if suit is filed or is not filed.
My consent on this page indicate that I agree that Millennium Eye Center (MEC) will receive payment for all services rendered, at the time they are rendered. Payment of services includes but is not limited to all co payments, deductibles and charges not covered by third party payers. I further understand that in the event that benefits are not verifiable, that I will be responsible for all charges estimated for services rendered for myself and all minors listed above.

PAYMENT RESPONSIBILITY FOR DIVORCED/SEPARATED PARENTS

The person who brought the child in for services is responsible for payment. This office cannot be responsible for collecting from any other individual.

OTHER FEES
• Cancellation fee for all orders is $50
• Returned check fee is $40
• All coupons must be presented at time of service
• Payment responsibility for missed appointments $50 fee
o To avoid this fee a 24 hour notice is required
o This payment is the responsibility of the patient: insurers do not cover this fee

• There are NO REFUNDS on professional services.
• There are NO REFUNDS of payments for materials once an order is processed.
• For Glasses:
o If patient is on a payment plan, follow the rules of that payment plan for refund of unprocessed orders.
• For Contacts:
o There are NO REFUNDS of professional exam fees.
o NO REFUND on materials once contacts are dispensed.
o However, we can do a one-time complimentary exchange of the unused contact lenses purchased from us. Boxes must be resalable, meaning – there should be no marks or writing, no torn or missing labels on boxes and each box must be factory sealed.

 There is a $20 processing fee for all exchanges.

LIFETIME INSURANCE ASSIGNMENT

In the event that I, the patient, am entitled to medical benefits or recovery of any type, arising from an insurance policy that ensures the patient or any other party liable to the patient such as but not limited to: private and group health, automotive liability, general liability, personal injury protection, medical payments, and uninsured or underinsured motorist benefits, that such benefits or recovery be hereby applied directly to Millennium Eye Center (MEC). As a patient, I understand that these benefits will be applied for payment of services rendered and provide consent for those benefits to be applied in the above stated manner. I am in full understanding that I am responsible for any and all charges not covered by these benefits.
Florida Statute Section 817.234 stipulates “any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement or claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.”
My initials in the patient signature page indicate- that I acknowledge that I have read the above statute and all information provided is accurate and true, to the best of my knowledge.



ASSIGNMENT OF MEDICARE & MEDICAID BENEFITS: CERTIFICATION, AUTHORIZATION FOR RELEASE, AND PAYMENT REQUEST (FOR MEDICARE & MEDICAID PATIENTS ONLY)

I certify that information provided when applying for payment under title XVIII of the Social Security Act is true and correct to the best of my knowledge. I hereby authorize any holder of information, medical or other to release this information and/or documents to the Social Security Administration or its intermediaries and carriers for use in this or related Medicare claim. I request for payment of these benefits to be made on my behalf.
I am in full understanding that benefits otherwise payable to the undersigned and /or patient to any involved physician(s) are to be paid by insurance benefits; however, I will be responsible for all charges not covered by said benefits. Charges that may not be covered include but are not limited to deductibles, co- insurance payments and any personal charges considered non-covered charges.