Privacy Policy
NOTICE OF PRIVACY PRACTICES AND PERSONAL RESPONSIBILITY FOR PAYMENT
THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Our pledge to protect your privacy: Mixan Eyecare, Inc is committed to protecting the privacy of your medical information. Your care and treatment is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with the providers involved in your care. We share your information only to the extent necessary to collect payment for the services we provide, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose your information for any other purpose without your permission.
Participant Rights: You have the following rights regarding your medical information: to request to inspect and obtain a copy of your medical records, subject to certain limited exceptions; to request to add an addendum to or correct your medical record; to request an accounting of Mixan Eyecare, Inc’s disclosures of your medical information; to request restrictions on certain uses or disclosures of your medical information; and to request that we communicate with you in a certain way or at a certain location.
We may use and disclose medical information about you for the following purposes: To provide you with medical treatment and services; to bill and receive payment for the treatment and services you receive; for functions necessary to run Mixan Eyecare, Inc and assure that our participants receive quality care; and as required or permitted by law. There are additional situations where we may disclose medical information about you without your authorization, such as: for workers’ compensation or similar programs; for public health activities (e.g., reporting abuse or reactions to medications); in response to a court or administrative order, subpoena, warrant or similar process; and to law enforcement officials in certain limited circumstances.
By signing this form you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke the Consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Mixan Eyecare, Inc provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
RESPONSIBILITY FOR PAYMENT
By signing this form, you confirm that you understand and agree that you are financially responsible for all charges for any and all services rendered. This includes any medical service or visit, routine examination, refraction, testing, contact lens services and any other screening ordered by the doctor or staff. While your insurance may confirm your benefits, confirmation of benefits is not a guarantee of payment and you are responsible for any unpaid balance.