Notice of Privacy Practices

General Rule

We respect our legal obligation to keep health information that identifies you, private. The law obligates us to give you notice of our privacy practices.

Generally, we can only use your health information in our office or disclose it outside of our office, without your written permission, for purpose of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.

Uses or Disclosures of Health Information

• Examples of how we use information for treatment purpose:
• When we set up an appointment for you.
• When our technician or doctor tests your eyes.
• When the doctor prescribes glasses or contact lenses.
• When the doctor prescribes medication.
• When our staff helps you select and order glasses or contact lenses.
• When we show you low vision aids.

We may disclose your health information outside of our office for treatment purposes, for example:

• If we refer you to another doctor or clinic for eye care or low vision aids or services.
• If we send a prescription for glasses or contacts to another professional to be filled.
• When we provide a prescription for medication to a pharmacist.
• When we phone to let you know that your glasses or contact lenses are ready to be picked up.

Sometimes we may ask for copies of your health information from another professional that you may have seen before.

We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:

• When our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services.
• When we prepare bills to send to you or your health or vision care plan.
• When we process payment by credit card and when we try to collect unpaid amounts due. 
• When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan.
• When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.
• You can ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.
• You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. Primarily, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally required. By law, we can have one 30-day extension of the time for use to give you access or photocopies if we sent you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.
• You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to person who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.
• You can get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.

Our Notice of Privacy Practices

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, and have copies available in our office.

Complaints

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to 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 Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

For More Information

If you want more information about our privacy practices, call or visit Julie Gussenhoven, OD at the address or phone number shown at the beginning of this notice.

VISION DISCOUNT PLAN: Our office accepts VSP (Vision Service Plan). You may have a vision discount plan separate from your major medical plan. Vision discount plans are utilized for a comprehensive eye exam for ocular wellness. Some vision discount plans allow for optical benefits which can be used to supplement the cost of vision correction via glasses and/or contact lenses.

MAJOR MEDICAL INSURANCE: Our office accepts most major medical insurance plans. We will bill all pertinent medical charges through your major medical plan.

COMPREHENSIVE EYE EXAMINATIONS: Routine annual eye examinations are billable to your vision discount plan. You are responsible for any co-pay at the time of your examination. In the event that pathology is detected during a routine wellness eye exam, additional testing or procedures may be indicated.

ADDITIONAL TESTING AND PROCEDURES ARE AT AN ADDITIONAL COST AND WILL BE BILLED TO YOUR MAJOR MEDICAL INSURANCE. IN THE CASE OF NO MEDICAL INSURANCE, THE COST OF THE ADDITIONAL TESTING WILL BE BILLED TO YOU DIRECTLY.

PATHOLOGY FOCUSED EYE EXAMINATIONS: Examinations for a medical complaint will be billed through your major medical insurance.

MEDICAL DIAGNOSIS: Diagnosis by your doctor of a medical condition during a comprehensive eye examination or pathology focused eye examination.

ADDITIONAL TESTING AND PROCEDURES: Testing to evaluate, to diagnose, or to manage a diagnosed pathology or condition. Additional testing and procedures may be independent from or in addition to a comprehensive eye exam. These tests may include but are not limited to: Fundus Photography, Wide Field Imaging, Anterior Segment Imaging, Visual Field Testing, Eye Lash Epilation, Foreign Body Removal, Serial Tonometry, Punctal Occlusion, OCT (Optical Coherence Tomography), Scleral Lens Fitting or other testing the Doctor deems necessary for the treatment or diagnosis of medical conditions.

NO-SHOW/CANCELLATION POLICY: Our office will charge a $75.00 no show fee for any missed appointments. If more than one appointment is cancelled consecutively, a $75.00 cancellation fee will apply. We ask that you notify the office about a cancellation at least 24 hours before your appointment.

LATE FEES: Any past due balance (90+ days) will receive a $10.00 late fee charge at the end of each month. Late fees will not be waived once they have been added to an account.

By Providing a cell phone number you agree to receiving text messages about your appointments or any other patient correspondence. Message and data rates may apply. If at any time you wish to op-out, please text STOP. We will not share your personal information unless written permission is granted.