Privacy Policy

NOTICE OF PRIVACY PRACTICES

Rajan Arora, OD

Privacy Official Effective Date: April, 2024

 We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices and abide by the policies within. This notice describes how we protect your health information and what rights you have regarding it.

 This Notice of Privacy Practices (“Notice”) describes how we may use or disclose your health information and how you can access such information. Please read it carefully. Your “health information,” for purposes of this Notice, is generally any information that identifies you and is created, received, maintained, or transmitted by us in the course of providing health care items or services to you (referred to as “health information” in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices regarding such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

Uses And Disclosures Of Information Without Your Authorization

The most common reasons we use or disclose your health information are for treatment, payment, or healthcare operations. Examples of how we use or disclose your health information for treatment purposes are setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. We use or disclose your health information for payment purposes by asking about your health or vision care plans or other payment sources, preparing and sending bills or claims, and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions we must carry out to run our office. Examples of how we use or disclose your health information for healthcare operations are financial or billing audits, internal quality assurance, personnel decisions, participation in managed care plans, defense of legal matters, business planning, and outside storage of our records.

Other Disclosures and Uses We May Make Without Your Authorization or Consent

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all these situations will apply to us; some may never come to our office. Such uses or disclosures are:

• when a state or federal law mandates that certain health information be reported for a specific purpose;
• for public health purposes, such as contagious disease reporting, investigation, or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
• disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
• uses and disclosures for health oversight activities, such as for the licensing of doctors for audits by Medicare or Medicaid or investigation of possible violations of health care laws;
• disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else;
• disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
• uses or disclosures for health-related research;
• uses and disclosures to prevent a serious threat to health or safety;
• uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or the evaluation and health of members of the foreign service;
• disclosures of de-identified information;
• disclosures relating to worker’s compensation programs;
• disclosures of a “limited data set” for research, public health, or healthcare operations;
• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• disclosures to “business associates” and their subcontractors who perform health care operations for us and who commit to respect the privacy of your health information by HIPAA;
• [specify other uses and disclosures affected by state law].

Unless you object, we will also share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were involved in your care or payment for health care before your death (such as your personal representative) health information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us before your death.

Specific Uses And Disclosures Of Information Requiring Your Authorization

The following are some specific uses and disclosures we may not make of your health information without your authorization:

Marketing activities. We must obtain your authorization before using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party, your authorization must also include consent to such payment.

Sale of health information. We do not currently sell or plan to sell your health information, and we must seek your authorization before doing so.

Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we must notify you that we generally must obtain your authorization before using or disclosing any such notes.

Your Rights To Provide Authorization For Other Uses And Disclosures

• Other uses and disclosures of your health information not described in this Notice will be made only with your written authorization.
• You may give us written authorization to use or disclose your health information to anyone.
• We will obtain your written authorization for using and disclosing your health information not identified in this Notice or otherwise permitted by applicable law.
• We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is to carry out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding using and disclosing your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we generally cannot retract any disclosures we may have already made with your permission. We may also be required to disclose health information as necessary for purposes of payment for services received by you before the date you revoked your authorization.

Your Individual Rights

You have many rights concerning the confidentiality of your health information. You have the right:

• To request restrictions on the health information we may use and disclose for treatment, payment, and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.
• To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests in writing to the address below. However, we reserve the right to determine if we can continue your treatment under such restrictive authorizations.
• To inspect or copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information, we may charge you a fee for copying, mailing, or other supplies. We may deny your request to inspect or copy your health information in certain circumstances, subject to applicable law.
• To amend health information. If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You must write to us at the address below to request an amendment. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information:
• was not created by us unless the person who created the information is no longer available to make the amendment,
• is not part of the health information kept by or for us,
• is not part of the information you would be permitted to inspect or copy, or
• is accurate and complete.
• To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years before the date of your request, and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper or electronically).
• To designate another party to receive your health information. Suppose you request access to your health information, which directs us to transmit a copy directly to another person. In that case, the request must be made by you in writing to the address below and must identify the designated recipient and where to send the copy.

Contact Person:

Our contact person for all questions, requests, or further information related to the privacy of your health information is noted below (Maria Vu).

Complaints:

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax, or E-mail above. If you prefer, you can discuss your complaint in person or by phone.

Changes to This Notice:

We reserve the right to change our privacy practices and apply the revised practices to your health information that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are available upon request at our reception area.

Acknowledgement Of Receipt

I acknowledge that I received a copy of _________________________________O.D., Notice of Privacy Practices.

Date ___________ Patient name________________________________ Signature _______________________________

 

Office Policies and Patient Financial Responsibilities

Form revised 04/2025

We aim to provide the best, personalized, professional eye care for you and your family. We provide:

• Routine eye examinations
• Medically related eye care
• Contact lens examinations

Routine Eye Examinations and Vision Care Plans:

A routine eye examination is for the following: near-sightedness, far-sightedness, astigmatism, presbyopia (difficulty seeing near due to increasing age), eyeglasses, and contact lenses. Nusight Vision is NOT contracted with any vision plans. However, we are an open-access provider and will work with you to use your vision insurance benefits for reimbursement by your vision plan. Payment in full is expected on the day of services. A routine eye examination does not cover diagnosing, managing, and/or treating medically related eye diseases.

Fees:

Our office is committed to providing the best treatment to our patients. Our fees represent the usual and customary charges for the level of service offered, the materials prescribed, and the level of advanced technology used to provide our patients with the most modern eye care in our area.

Non-Covered Services:

Please be aware that some, and perhaps all, of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or major medical and vision insurers. These services may be required to be paid in full at your visit or after we receive your explanation of benefits.

Refraction:

Medicare and most other medical insurance plans no longer pay for refractions. The refraction is the test performed during your office visit to determine your best possible prescription (“Which is better, one or two?”). A refraction is also required to assess the health of your eyes. You will be asked to pay for the refraction at the end of your visit. The fee for this test is $81.00.

Consent to Treat:

I request and consent to Nusight Vision to provide and perform such medical and vision eye care, tests, procedures, medications, and other services and supplies considered medically necessary or beneficial for my eye and vision health.

****Initial:

Payment: You are responsible for co-pays, co-insurance, deductible, and other non-covered services. Any surcharges for spectacle upgrades set by your vision insurance must be paid at the time of service before any orders will be processed. If you are a self-pay patient and/or your insurance cannot be verified before your appointment, you must pay in full the day services are rendered.

We accept cash, personal checks, all major credit cards, and Care Credit. If you are being seen for any ongoing medical problems, co-pays are due at each and every visit. If you foresee any payment problems, please speak to our office staff before your appointment.

Claims Filing:

As a courtesy to our patients, we will file medical claims with medical insurance companies for which we are providers. We will do our best to accurately verify benefits for services and/or materials; however, benefits quoted by your insurance carrier are not guaranteed payment. Should your insurance deny a claim for any reason, you will be responsible for any remaining balances as directed by your insurance.

Patients who receive a statement from our office are expected to remit full payment upon receipt unless previous payment arrangements were made with our billing office. If your account must be referred to an outside collection agency for non-payment, a fee will be added to cover the expense incurred by the agency. Patients in collections must make payment arrangements before scheduling another appointment with our office. If you receive a billing statement you do not understand, please contact our office.

Proof of Insurance:

We are required by law to get an up-to-date copy of your insurance card(s) before you see the eye doctor. If you do not present this at the time of your visit or fail to provide us with the correct insurance information, you will be responsible for the balance of the claim.

Secondary Insurance:

If you have secondary medical insurance, it is your responsibility to have them set up to crossover with each other. Any balance that does not automatically crossover to your secondary insurance will be your responsibility. We will provide you with an itemized receipt that you can send with a copy of your explanation of the benefits you received from your primary insurance for possible reimbursement.

Non-Payment:

If we do not receive payment from your insurance company within 60 days, the balance will automatically be billed to you. If your account is over 90 days past due, you will receive a letter stating that you have 21 days to pay your account in full. Partial payments will not be accepted unless previously discussed. We may refer your account to a collection agency if a balance remains unpaid. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative eye care. During that 30-day period, our office can only treat you on an emergency basis.

Missed Appointments:

Once your appointment has been confirmed, it will be reserved for you to meet your eye care needs. Please be courteous to our staff and fellow patients by keeping your confirmed appointment. If you cannot keep your scheduled appointment, please inform us immediately. We do require a 24-hour notice of cancellation of your scheduled appointment. A minimum fee of $50.00 may be charged to your account for broken appointments based on the time and service reserved for you. If you do not cancel 24 hours in advance or do not show up for your scheduled appointment 3 times in a 12-month period, we have the right to dismiss you from our care.

 

I authorized Nusight Vision to act as my agent when applying for insurance and/or Medicare benefits. I authorize payment of these benefits directly to Nusight Vision on my behalf. I authorize any holder of medical information about me to release information needed to determine benefits payable for related services. If I have additional insurance, my signature authorizes the release of the above medical information to any insurer or agency I have given. It authorizes my doctor to act as my agent above.

(Required)

With my signature below, I confirm that I have been informed of and agree with the policies and insurance authorization outlined above. Unless revoked by me in writing, this authorization is adequate for my lifetime.

First Name

Last Name

Signature

Patient or Responsible Party

Date