YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. This right does not include psychotherapy notes, information compiled for use in a legal proceeding or certain information maintained by laboratories. In order to inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer listed on the last page of this Notice for the location at which you were treated. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request in writing that the denial be reviewed. To request a review, contact the Privacy Office. This contact information is listed on the last page of this Notice. A licensed healthcare professional will conduct the review. We will comply with the outcome of the review.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you:
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. With certain exceptions, you have the right to inspect and/or obtain a copy of your medical records via written request. Any additional copies of your records will be subject to a reasonable charge. You have the right to request an addendum or amendment to this agreement via written request. By signing this form, you are agreeing that you have read and understand this notice. Patient’s Name: Patient’s Signature: Date: Guardian’s Signature (if under 18 years old): Date: HIPAA- Health Insurance Portability and Accountability Act Notice of Privacy Practices HIPAA is the Health Insurance Portability and Accountability Act, a federal law that requires health providers take certain steps to protect the privacy and security of patient health information. The privacy of your health and medical records are important to us. We are committed to protecting it. This notice will provide with you some of the ways we may use and/or share your medical information about you. iSight Vision Care, Inc. originates and maintains medical health records that describe your health history, symptoms, examination, test results, diagnosis, treatment, and any plans for future care or treatment. These records are the property of iSight Vision Care, Inc. This information can be used to serve as, but is not limited to: A basis for planning your care and treatment A means of communication among health professionals who contribute to your care A source of information for applying my diagnosis and surgical information to your medical claim and/or bill A means for disclosing information to law and health official authorities with preventing or controlling disease, injury, or disability Disclosure of Medical Records By signing below, I certify that all medical information pertaining to my care may be shared by the staff and doctors at iSight Vision Care, Inc to the individuals listed below: Name: Relationship to Patient: Name: Relationship to Patient: Patient Signature: Date: PATIENT HEALTH HISTORY QUESTIONAIRE LAST NAME FIRST NAME M.I. DATE OF BIRTH / / DATE OF LAST EXAM WERE YOUR PUPILS DILATED? DO YOU WEAR GLASSES? CONTACT LENSES? IF SO, WHAT TYPE? / / YES / NO YES / NO NO SOFT TORIC RGP PATIENT EYE HISTORY HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE EXPLAIN BELOW. EYE OPERATIONS? YES / NO EYE INJURIES? YES / NO DRY EYES? YES / NO CATARACTS? YES / NO GLAUCOMA? YES / NO MACULAR DEGENERATION? YES / NO OTHER EYE PROBLEMS? YES / NO FAMILY EYE HISTORY HAS ANYONE IN YOUR FAMILY E...
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. With certain exceptions, you have the right to inspect and/or obtain a copy of your medical records via written request. Any additional copies of your records will be subject to a reasonable charge. You have the right to request an addendum or amendment to this agreement via written request. By signing this form, you are agreeing that you have read and understand this notice. Patient’s Name: Patient’s Signature: Date: Guardian’s Signature (if under 18 years old): Date: PATIENT HEALTH HISTORY QUESTIONAIRE LAST NAME FIRST NAME M.I. DATE OF BIRTH / / DATE OF LAST EXAM WERE YOUR PUPILS DILATED? DO YOU WEAR GLASSES? CONTACT LENSES? IF SO, WHAT TYPE? / / YES / NO YES / NO NO SOFT TORIC RGP PATIENT EYE HISTORY HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE EXPLAIN BELOW. EYE OPERATIONS? YES / NO EYE INJURIES? YES / NO DRY EYES? YES / NO CATARACTS? YES / NO GLAUCOMA? YES / NO MACULAR DEGENERATION? YES / NO OTHER EYE PROBLEMS? YES / NO FAMILY EYE HISTORY HAS ANYONE IN YOUR FAMILY EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE EXPLAIN BELOW. HIGH BLOOD PRESSURE? YES / NO DIABETES? YES / NO CATARACTS? YES / NO GLAUCOMA? YES / NO MACULAR DEGENERATION? YES / NO RETINAL DETACHMENT? YES / NO OTHER EYE PROBLEMS? YES / NO PATIENT MEDICAL HISTORY HAVE YOU EVER HAD ANY OF THE FOLLOWING? IF SO, PLEASE EXPLAIN BELOW. IRREGULAR HEART RHYTHM? YES / NO HIGH BLOOD PRESSURE? YES / NO DIABETES? YES / NO COPD? YES / NO ASTHMA? YES / NO URINARY INCONTINENCE? YES / NO CANCER? YES / NO ALLERGIES TO MEDICATION? YES / NO ALLERGIES TO OTHER THINGS? YES / NO OPERATIONS IN GENERAL? YES / NO PLEASE CIRCLE SMOKING ALCOHOL RECREATIONAL DRUGS NEVER SMOKED FORMER SMOKER SMOKES EVERYDAY SMOKES SOME DAYS NEVER SOCIALLY 1 GLASS PER DAY 1+GLASS PER DAY NO / YES IF YES, PLEASE LIST: PLEASE LIST ANY MEDICATIONS YOU ARE TAKING PATIENT’S SIGNATURE: DATE: INSURANCE POLICIES iSight Vision Care, Inc. is currently contracted to be In-Network with the following PPO Plans and 1 HMO plan. Note: These plans are subject to change without notice AARP Aetna Blue Cross Blue Shield Cigna Health Net Humana Medicare Medi-Cal (Secondary to Medicare) Tricare/Triwest United Food Worker Union United Health Care HMO MemorialCare Medical Group
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your benefits. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to your Executive Director. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the right to request a copy or view your medical information that we use to make a decision about your care. You may be charged a fee for the copies. If you believe that your information in your record is incorrect or important information is missing, you have the right to request we amend the records. You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent. CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
