Office Policy

Payments are due at time of service. For our patients with insurance, our contracts with insurance companies require us to collect your co-pay at the time of service. Payment is also due at time of service for any portion of your visit not covered by your insurance. We accept cash, check, and Visa/Mastercard. If your personal check is returned due to non-sufficient funds, a returned check fee of $25.00 will be charged to your account.

Glasses prescriptions are guaranteed for 90 days from the date of exam. Any changes to the prescription occurring after the 90 days from the date of exam will incur an office visit fee.

Contact lens follow-up care will be charged as an office visit if beyond 90 days of exam or after a contact lens prescription has been dispensed. Contact lens care beyond six months from the date of exam will incur a new exam fee. First time contact lens wearers are required to be trained in office prior to release of contacts. Each hour of training is $25.00.

As a courtesy to our patients, we will file your insurance claim after each visit. If your insurance company has not paid your claim within 90 days, you will be required to pay in full. Our office does not enter into disputes with insurance companies over coverage. It is your responsibility to resolve any disputes over payments by your insurance.

Should a billing statement be sent to you, you will have 30 days to pay any outstanding balance. Thereafter, late payment charges of $8.00 per month will be added to your account. In the event your account is forwarded to collections, you agree to reimburse our office the fees of any collection agency and all costs and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

Many patients have both medical and vision benefits. Vision Plans are designed to cover a prescription for glasses and help pay for lenses. It is not intended to cover medical conditions and treatments. Medical insurance applies to situations when a medical problem affects the eyes (such as diabetes, cataracts, and glaucoma, to name a few). When such conditions are being managed, vision plans do not cover these issues. We are obligated to comply with the regulations set forth by insurance companies.

If we are not on your insurance company's panel, we can provide you, upon your request, with an itemized receipt so that you may file a claim with your insurance company for reimbursement. The amount of reimbursement depends on your vision plan coverage.

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health information for treatment purposes are: setting up, confirming, or reminding you about appointments, eye examinations, recommended recall visits, or follow-up care; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and sending prescriptions to be filled; providing status updates about eyeglasses, contact lenses, or other optical orders, including notice that an order is being processed, is delayed, is ready for pickup, or requires follow-up; 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. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; 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 that we must carry out in order to run our office.

Examples of how we use or disclose your health information for health care 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.

If you provide us with a mobile telephone number or email address, we may use it to send nonmarketing communications related to your care and our services, including appointment confirmations and reminders, reminders that you are due for a routine or recommended recall examination, follow-up reminders, and optical order status or pickup updates. These communications may be sent through automated technology and may contain limited health information. We will use reasonable safeguards and limit the information included to what is reasonably necessary for the communication.

Text messages and unencrypted email may have privacy risks because they could be seen by another person with access to your device, telephone number, or email account. You may ask us to contact you by a different reasonable method or at a different location. You may also ask us to stop sending nonessential text messages or emails. To stop text messages, reply STOP or contact us using the information below. Message and data rates may apply. These communications will not include marketing, advertising, or promotional content unless you have separately authorized or consented to such communications as required by applicable law.

In some limited situations, the law allows or requires us to use or disclose your health information without your consent or authorization. Not all of these situations will apply to us; some may never come up at our office at all. 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 for 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 for 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 health care 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 in accordance with HIPAA;

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 prior to 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 prior to your death.

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 prior to 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 prior to doing so.
• Psychotherapy notes. Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization. You may give us written authorization permitting us to use your health information or to disclose it to anyone for any purpose. We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not 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 for the purpose of carrying 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 the use and disclosure of 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 are generally unable to retract any disclosures that we may have already made with your authorization. We may also be required to disclose health information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

• 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 (See Contact Person).
• 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 will be able to 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 the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
• To amend health information. If you feel that health information, we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. 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:
  • If it was not created by us, unless the person that 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 prior to the date of your request and may not include dates before August 15, 2020. Your request must state how you would like to receive the report (paper, electronically).
• To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person, the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.

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 the office contact person at the address, fax or Email shown above. If you prefer, you can discuss your complaint in person or by phone.

We reserve the right to change our privacy practices and to apply the revised practices to health information about you 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 also available upon request at our reception area.

By agreeing to our Office Policy, you authorize GoTo Eye Associates, LLC d/b/a GoTo Optical ("GoTo Optical," "we," "us") to send you marketing and promotional communications using the mobile number, email address, and mailing address you provide on this form or update later.

These messages may be sent through automated technology. Consent to marketing is for promotional communications and is separate from the care-related reminders described in our Notice of Privacy Practices.

Marketing communications may include:

• Specials on eyewear, contact lenses, and related products
• New frame collections, brands, or in-office events
• Seasonal offers and limited-time promotions
• Practice news that is promotional rather than related to your care

We may contact you by email, text message (SMS/MMS), phone call, or mail. Text messages and phone calls may use an automatic telephone dialing system or prerecorded/artificial voice. Message frequency varies. Message and data rates may apply.

We do not sell your health information. If a marketing message would use or disclose your health information, we will do so only as permitted by HIPAA and this authorization, or with a separate written authorization when the law requires one. Routine appointment reminders, recall notices, and optical order updates are not marketing and are described in our Notice of Privacy Practices.

We may update this Marketing Policy from time to time. The current version will be posted on our website. Continued use of the contact information you provided after a change is posted means you accept the updated policy, unless you have opted out.