CANCELLATIONS OF APPOINTMENTS/NO SHOWS

WHEN YOU DO NOT SHOW UP FOR A SCHEDULED APPOINTMENT, IT CREATES AN UNUSED APPOINTMENT SLOT THAT COULD HAVE BEEN USED FOR
ANOTHER PATIENT. IT IS VERY IMPORTANT THAT YOU CALL WITHIN 24 HOURS IN ADVANCE TO CANCEL YOUR APPOINTMENT. IF FOR ANY REASON
YOU NEED TO CANCEL AN APPOINTMENT, PLEASE NOTIFY OUR OFFICE AS A SOON AS POSSIBLE. ON YOUR SECOND NO-SHOW OCCURRENCE, THERE
WILL BE A $59 CHARGE TO YOUR ACCOUNT. AFTER THREE CONSECUTIVE NO-SHOW OCCURRENCES, THE PRACTICE MAY ELECT TO TERMINATE OUR
RELATIONSHIP WITH YOU.

FINANCIAL POLICY

THANK YOU FOR CHOOSING BRILLIANT EYECARE AS YOUR MEDICAL EYE CARE AND VISION CARE PROVIDER. WE ARE COMMITTED TO PROVIDING
YOU AND YOU’RE FAMILY WITH THE BEST AVAILABLE MEDICAL AND VISION CARE. IN OUR ONGOING PROCESS TO MAKE SURE THAT ALL OF YOUR
MEDICAL NEEDS ARE MET, OUR BILLING DEPARTMENT WILL BE AVAILABLE TO DISCUSS OUR FEES AND THIS POLICY WITH YOU. WE ASK THAT ALL
RESPONSIBLE PARTIES READ AND SIGN OUR FINANCIAL POLICY AS WELL AS COMPLETE THE PATIENT FORMS PRIOR TO SEEING THE DOCTOR.
PAYMENTS FOR ALL SERVICES WILL BE DUE AT THE TIME SERVICES ARE RENDERED. IN ORDER TO SERVE YOU BETTER, WE ACCEPT CASH, CHECK,
VISA, MASTERCARD, AMEX, DISCOVER, CARE CREDIT, FLEX SPENDING. AS A COURTESY TO YOU, IT IS THE POLICY OF BRILLIANT EYECARE TO BILL
YOUR INSURANCE CARRIER, ALTHOUGH YOU ARE ULTIMATELY RESPONSIBLE FOR THE ENTIRE BILL.
1. YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU, YOUR EMPLOYER, AND THE INSURANCE COMPANY. WE ARE NOT A PARTY TO THAT
CONTRACT. OUR RELATIONSHIP IS WITH YOU, NOT YOUR INSURANCE COMPANY. WE WILL NOT BECOME INVOLVED IN DISPUTES BETWEEN YOU
AND YOUR INSURER REGARDING DEDUCTIBLES, CO-PAYMENTS, COVERED CHARGES, AND SECONDARY INSURANCE CHARGES. AS YOUR MEDICAL
PROVIDER, WE WILL ONLY SUPPLY FACTUAL INFORMATION TO FACILITATE CLAIM PROCESSING.
2. FEES FOR SERVICES, WHICH INCLUDE UNPAID BALANCES, DEDUCTIBLES AND CO-PAYMENTS, ARE DUE AT THE TIME OF SERVICE. RETURNED
CHECKS AND UNPAID BALANCES MAY BE SUBJECT TO COLLECTION PLACEMENT AND/OR SERVICE FEES.
3. ALL CHARGES ARE YOUR RESPONSIBILITY WHETHER YOU’RE INSURANCE COMPANY PAYS OR DOES NOT PAY. IF YOUR INSURANCE CARRIER
DOES NOT REMIT PAYMENT WITHIN 60 DAYS, THE BALANCE WILL BE DUE IN FULL FROM YOU. IF ANY PAYMENT IS MADE DIRECTLY TO YOU FOR
SERVICES BILLED BY BRILLIANT EYECARE, YOU RECOGNIZE AN OBLIGATION TO PROMPTLY REMIT PAYMENT TO BRILLIANT EYECARE.
4. I UNDERSTAND AND AGREE THAT IF I FAIL TO MAKE ANY OF THE PAYMENTS FOR WHICH I AM RESPONSIBLE IN A TIMELY MANNER, AFTER SUCH
DEFAULT AND UPON REFERRAL TO A COLLECTION AGENCY OR ATTORNEY BY BRILLIANT EYECARE, I WILL BE RESPONSIBLE FOR ALL COST OF
COLLECTING MONIES OWED, INCLUDING COURT COST, COLLECTION AGENCY FEES, AND ATTORNEY FEES.
5. I UNDERSTAND THAT IF I DO NOT SHOW FOR A SCHEDULED APPOINTMENT WITHOUT GIVING A 24 HOUR NOTICE I AM SUBJECT TO A $59 NO SHOW
FEE.

PATIENT HIPAA CONSENT FORM

I UNDERSTAND THAT I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION. THESE RIGHTS ARE GIVEN TO ME
UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA). I UNDERSTAND THAT BY SIGNING THIS CONSENT I
AUTHORIZE YOU TO USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION TO CARRY OUT:
• TREATMENT (INCLUDING DIRECT OR INDIRECT TREATMENT BY OTHER HEALTHCARE PROVIDERS INVOLVED IN MY TREATMENT);
• OBTAINING PAYMENT FROM THIRD PARTY PAYERS (E.G. MY INSURANCE COMPANY);
• THE DAY-TO-DAY HEALTHCARE OPERATIONS OF YOUR PRACTICE.
I HAVE ALSO BEEN INFORMED OF AND GIVEN THE RIGHT TO REVIEW AND SECURE A COPY OF YOUR NOTICE OF PRIVACY PRACTICES, WHICH
CONTAINS A MORE COMPLETE DESCRIPTION OF THE USES AND DISCLOSURES OF MY PROTECTED HEALTH INFORMATION AND MY RIGHTS UNDER
HIPAA. I UNDERSTAND THAT YOU RESERVE THE RIGHT TO CHANGE THE TERMS OF THIS NOTICE FROM TIME TO TIME AND THAT I MAY CONTACT
YOU AT ANY TIME TO OBTAIN THE MOST CURRENT COPY OF THIS NOTICE.

I UNDERSTAND THAT I HAVE THE RIGHT TO REQUEST RESTRICTIONS ON HOW MY PROTECTED HEALTH INFORMATION IS USED AND DISCLOSED TO
CARRY OUT TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS, BUT THAT YOU ARE NOT REQUIRED TO AGREE TO THESE REQUESTED
RESTRICTIONS. HOWEVER, IF YOU DO AGREE, YOU ARE THEN BOUND TO COMPLY WITH THIS RESTRICTION.

I UNDERSTAND THAT I MAY REVOKE THIS CONSENT, IN WRITING, AT ANY TIME. HOWEVER, ANY USE OR DISCLOSURE THAT OCCURRED PRIOR TO
THE DATE I REVOKE THIS CONSENT IS NOT AFFECTED.