Office Policies

HARLAN EYE CARE – Consent for Portal Delivery of Prescription(s):

Under federal law, you have an absolute right to obtain a paper copy of your (or your dependent’s) glasses and/or contact lens prescription(s) immediately after completion of the glasses exam or immediately after completion of the contact lens evaluation process. If requested, this will be provided at no additional cost to you. To provide you with secure, continuous access to your prescriptions and to aid in our commitment to reduce the use of paper, Harlan Eye Care offers digital delivery of prescriptions via our “CrystalPM Patient Portal”. Your prescription copy/copies will be uploaded immediately upon completion of the glasses exam or contact lens evaluation process. By signing below, you confirm that Harlan Eye Care has automatically created an active patient portal profile and will provide you (or your dependent’s) easy access to the portal if desired. You acknowledge that you may securely access, download, and print your prescription(s) from this portal at your convenience. You may indefinitely revoke this acknowledgment at any time and request a valid paper or electronically delivered copy of your prescription(s) at any time.

HARLAN EYE CARE – Payment for Services, Financial Responsibility, and Authorization for Release of Health Information:

Harlan Eye Care sincerely appreciates the opportunity to serve you. Your understanding of the topics below is important to us. Please inform us if you have any questions.

Insurance Participation: Vision insurance coverage at Harlan Eye Care often differs between plans. Please ask us about your specific vision coverage if you have questions. We participate with various medical insurances. Your medical insurance may be filed if your primary reason for visiting is related to a medical eye condition. Proof of active medical coverage is required at the time of service for us to file your medical insurance. Please ask us about your specific medical coverage if you have questions.

Patient Responsibility: Please be advised that payment for all services and products is the responsibility of the patient and is due at the time of service. If your exam is filed to medical insurance, you acknowledge that the charges constitute a contract between you, your employer, and your insurance company. While we file your medical claims as a courtesy, it is essential to note that not all services may be covered under your plan. It is your responsibility to understand your benefits.

Accepted Payment Methods: We accept cash, all major credit cards, and FSA/HSA benefit cards.

Agreement to Pay: If applicable, by signing below, you agree to pay all copays, deductibles, co-insurances, and any non-covered services as determined by your insurance company. Balances are to be settled promptly, and any past due accounts may incur additional collection fees.

Authorization for Release of Information: You hereby authorize the release of any medical/health information and treatments to your insurance company, if applicable. Additionally, you authorize the release of your personal medical/health information to any practitioner/clinic to whom you may be referred or to whom we may correspond with about your care.

Understanding of Insurance Verification: It is important to understand that verification of eligibility does not guarantee payment, as stipulated by your insurance company.

Acknowledgement of the Above: My signature indicates that I have read and agree to all the above.

HARLAN EYE CARE – HIPAA Authorization for Use or Disclosure of Health Information:

Our Notice of Privacy Practices provides information about how Harlan Eye Care may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

My Authorization: My signature below authorizes Harlan Eye Care to share all my health information with any individuals that I list (with phone number).

My Rights: I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke the authorization if its purpose was to obtain insurance. I understand that treatment by any party may not be conditioned upon my signing of this authorization and that I have the right to refuse to sign this authorization.

Notice of Privacy Practices: My signature indicates that I have been provided with a copy of the Notice of Privacy Practices (included in this document) and that I understand its content.

HARLAN EYE CARE – Notice of Privacy Practices:

Your Information, Your Rights, Our Responsibilities: 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. You can 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. Ask us how to do this. We will provide a copy or a summary of your health information. 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. Ask us how to do this. We may 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 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 operation. 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 you r 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 on accounting a year for free but will charge a reasonable, cost-based fee if you ask for another on 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 the 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 at 901-654-5654. 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 Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. 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 you information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: share information with you family, close friends, or other involved in your care; share information in a disaster relief situation; include your information in a hospital directory. 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; most sharing of psychotherapy notes. In the case of fundraising: we may contact you for fundraising efforts, but you can tell us not to contact you again.

Other 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. 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. 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. 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/understanding/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 medication, 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 laws require it, including wit 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 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/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice: We can change the terms of this notice, 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.