Notice of Practice’s Privacy Committee (888-212-3937)
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 the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to
provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy of privacy practices with respect to protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. lf you have any questions about this Notice, please call Orna Benedek, the contact officer of the Privacy Committee listed above.
Acknowledgement of Receipt of Notice of Privacy Practices
I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.
Insurance Billing
Information which the insurance company may request concerning my present illness or injury. I hereby assign to the doctor whose name appears above all the money to which I am entitled for medical and/or surgical expenses relative to the service reported above. I understand that I am financially responsible to the said doctor(s) for charges not covered by this assignment. NO INSURANCE: Payment is due at the time of service; however, we do allow financial arrangements. Non-paid accounts are referred to a collection agency ninety (90) days after the first charge. INSURANCE: Co-payments, deductibles, or non-covered charges are due at the time of service. Non-paid accounts are referred to a collection agency one hundred and twenty (120) days after the first charge. We may bill your insurance for you; however, this does not release your responsibility for payment on any charges not paid by your insurance.
Consent For E-mail Communication
I hereby consent to E-mail communication between New York Ophthalmology and myself, for the explicit purpose of receiving login instructions and information for the online patient portal. The online patient portal is a secure website through which New York Ophthalmology can communicate with patients who have created accounts. CMS (Center for Medicare & Medicaid Services) has mandated that healthcare professionals providing services to Medicare and Medicaid patients must provide patients with the ability to view online patient health information. I also consent to informational emails and non-patient specific reminders. E-mail will never be used for communications regarding patient identifiable medical or financial issues. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on E-mail or the patient portal. New York Ophthalmology, will not sell or distribute Emails to third parties for commercial or marketing purposes.
Consent For SMS Appointment Communication
I hereby consent to SMS communication between New York Ophthalmology and myself, for the explicit purpose of receiving appointment changes and reminders and relevant communication.
Consent For Use of Electronic Prescription Information
I agree that New York Ophthalmology may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for medical care and treatment purposes.
