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Stephen E. Smith, MD

Eye Associates of Fort Myers

 

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Insurance Information

Patient's or Authorized Signature

Guarantor Information

Review of Systems

Privacy Practice Acknowledgment Form

Privacy Practice Acknowledgment Form

Additional Information

Patient Medical History

I authorize the release of any medical or other information necessary to process this claim. I request payment of government benefits and/or medical insurance benefits either to myself or to the party who accepts assignment.

(Person responsible for payment if different from self):

Have you ever been treated for or told you have any of the following?

By signing this form, I authorize the use and disclosure of my health information as described in the Eye Associates Notice of Privacy Practices. I have received the Eye Associates Notice of Privacy Practices and I have been provided an opportunity to review it. This notice is effective as of the date below and will remain effective until further notice

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.

Patient Health Information

Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information. Your information may be stored electronically and if so is subject to electronic disclosure.

 

How We Use & Disclose Your Patient Health Information

 

Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.

 

Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment or disclose your information to payors to determine whether you are enrolled or eligible for benefits. We will submit bills and maintain records of payments from your health plan.

 

Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, arranging for legal services and to assess the care and outcomes of your case and others like it.

 

Special Uses and Disclosures

Following a procedure, we will disclose your discharge instructions and information related to your care to the individual who is driving you home from the center or who is otherwise identified as assisting in your post-procedure care. We may also disclose relevant health information to a family member, friend or others involved in your care or payment for your care and disclose information to those assisting in disaster relief efforts.

 

Other Uses and Disclosures

We may be required or permitted to use or disclose the information even without your permission as described below:

Required by Law: We may be required by law to disclose your information, such as to report gunshot wounds, suspected abuse or neglect, or similar injuries and events.

Research: We may use or disclose information for approved medical research.

Public Health Activities: We may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.

Health oversight: We may disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.

remind you of appointments.

 

In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for copies.

 

You have the right to request that we amend your information.

 

You may request a list of disclosures of information about you for reasons other than treatment, payment, or health care operations and except for other exceptions.

 

You have the right to obtain a paper copy of the current version of this Notice upon request, even if you have previously agreed to receive it electronically.

 

Our Legal Duty

We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect. We are required to notify affected individuals in the event of a breach involving unsecured protected health information.

 

Changes in Privacy Practices

We may change this Notice at any time and make the new terms effective for all health information we hold. The effective date of this Notice is listed at the bottom of the page. If we change our Notice, we will post the new Notice in the waiting area. For more information about our privacy practices, contact the person listed below.

 

Complaints

If you are concerned that we have violated your privacy rights, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below will provide you with the appropriate address upon request. You will not be penalized in any way for filing a complaint.

 

Contact Person

If you have any questions, requests, or complaints, please contact:

 

Ed Cropper, RN, BSN, Admin

4225 Evans Ave., Ft. Myers, FL 33901

(239) 936-7685

Judicial and administrative proceedings: We may disclose information in response to an appropriate subpoena, discovery request or court order.

 

Law enforcement purposes: We may disclose information needed or requested by law enforcement officials or to report a crime on our premises.

 

Deaths: We may disclose information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.

Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

 

Military and Special Government Functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes.

 

Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work- related injuries or illness.

Business Associates: We may disclose your health information to business associates (individuals or entities that perform functions on our behalf) provided they agree to safeguard the information.

 

Messages: We may contact you to provide appointment reminders or for billing or collections and may leave messages on your answering machine, voice mail or through other methods.

 

In any other situation, we will ask for your written authorization before using or disclosing identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your health information for marketing purposes or sell your health information, unless you have signed an authorization.

 

Individual Rights

You have the following rights with regard to your health information. Please contact the Contact Person listed below to obtain the appropriate form for exercising these rights.

You may request restrictions on certain uses and disclosures. We are not required to agree to a requested restriction, except for requests to limit disclosures to your health plan for purposes of payment or health care operations when you have paid in full, out-of-pocket for the item or service covered by the request and when the uses or disclosures are not required by law.

 

You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to

Office Policy Regarding Payment

Please read over the following information very carefully before seeing the doctor. This is to eliminate any confusion regarding office policies. Thank you!

 

Medicare: We accept Medicare assignment. Medicare assignment means we will be reducing our fees to the Medicare allowed amounts. Medicare will pay 80% of the allowed amount leaving 20% co-payment to your responsibility. As a courtesy, we are happy to file your supplement to your secondary insurance for you. However, if your supplement pays directly to you, you will be responsible for the 20% today plus any non-covered services (example: refractions). Medicare has a deductible of $183.00 per calendar year. You are required by Medicare to pay the first $183.00 for any outpatient medical expense if you have not met your deductible.

 

Medicaid Plans: You may be responsible for a $40.00 refraction fee at the time services are rendered.

 

Managed Care Plans (HMO or PPO): Your plan requires you to pay your co-pay at the time of service. HMO plans are required to have an authorization number or referral slip from your primary care physician. If this is not obtained prior to your visit, you will be responsible for full payment at the time services are rendered.

 

Private/Commercial/Group Insurance: You are responsible for payment at time of service. This includes any applicable co-pay, co-insurance and deductible.

 

No Insurance: Unless prior arrangements have been made with our office, full payment is due at the time services are rendered.

 

Refractions: To ensure your continued eye health, Eye Associates recommends a refraction exam to determine your best corrected vision. It is important for the doctor to know if you have a decrease in your best corrected vision. In addition, a refraction will determine if your vision might be improved with glasses or contacts. A prescription written from the results of the refraction is required in order to purchase prescription glasses or contacts. Unfortunately this test is not covered by Medicare, Medicaid and most Insurance. Your out of pocket expense for this test is $40.00.

Stephen E. Smith, MD

Eye Associates of Fort Myers

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Eye Care For You!

 

Request an Appointment

Fort Myers

(239) 936-7685

4225 Evans Avenue

Fort Myers, Florida 33901

Hours: M-F 8am - 5pm

 

Naples

(239) 593-7747

7955 Airport Pulling Rd N Suite 104

Naples, Florida 34109

Hours: M-F 8am-5pm

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