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PATIENT INFORMATION AT SHETTLE FAMILY EYE
CARE & EYE WEAR - DR. SCOTT SHETTLE
APPOINTMENTS: It is recommended
that appointments be scheduled in order to see you on a timely
basis. We value your time and every effort will be made to see you
on schedule. Please understand, that if you are more than 15 minutes
late for your appointment, we will attempt to work you back into the
schedule as time permits, or if you wish, you may reschedule. We
welcome walk-ins with the understanding that patients with
appointments have priority.
PAYMENT: At Shettle Family Eye Care & Eye Wear we accept
cash, personal checks, debit cards, Visa/MasterCard, and American
Express.
Payment is due when services are rendered. We welcome most health
care plans and offer a discount if we are an out of network
provider. Check with our office for details. Insurance carriers many
times will pay less than the actual bill for services or products.
Patient payment responsibilities include co-pays, uncovered charges,
denied charges, and any insurance balances outstanding beyond 90
days from the date the claim was filed.
Contact Lens Evaluations and Fittings: If you are new to our
office, new to contacts, or need/want to switch lens types, a
fitting is required, which includes the evaluation of the lenses,
follow up appointments and trial lenses, if applicable. Fitting fees
range from $50-$150.
(Current patients who are contact lens wearers:) Contact lenses are
medical devices and even though they may feel fine, there are health
risks involved. In order to renew your contact lens prescription,
additional testing and monitoring is required. This is not part of
the standard eye exam and a update fee will be charged.
Special Orders: Special Order contact lenses must be paid for
in full before the order is placed. There are no returns on these
items with the exception of an obvious manufacturers defect.
Special Order frames or spectacle lenses must have at least a 50%
deposit before the order will be placed. Cancellations or returns
will require our lab to keep a portion of the deposit (usually 30%)
to cover any charges that were incurred. Frame orders on approval
will be limited to two per patient.
Warranties and Returns: We appreciate your confidence in our
quality eye care products. Shettle Family Eye Care & Eye Wear is proud of
our one year bumper-to-bumper warranty on complete pairs of
eyeglasses made at our office. This covers frame breakage or lens
scratching under normal wearing conditions.
We want you to be happy with your new eyeglasses. If for some reason
you are unhappy with your purchase, you may return your eyeglasses
within 14 days for exchange.
Insurance Listing:
Vision Service Planฎ (VSPฎ)
EyeMed Vision Care
Humana
Superior Vision
United Health Care-Secure Horizons
United Health Care
Humana/CompBenefits/Vision Care Plan (VCP)
TriCare
Notice of Privacy Practices
Effective date of notice: 04/01/2003
D. Scott Shettle, OD, P.A. d/b/a Shettle Family Eye Care & Eye
Wear
This notice describes how medical information about you may be used
and disclosed, and how you can obtain access to this information.
Please review it carefully.
General Rule
In order to comply with quality of care mandates, as well as to meet
state and federal requirements, it is necessary that all doctors
develop a privacy policy. 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 purposes 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. Please note that
in each instance only the minimum amount of information required to
accomplish a certain task will be released. The only exception to
this would be for treatment by another healthcare provider.
In addition to the law, we would like you to know that all Shettle
Family Eye Care & Eye Wear employees have signed an agreement to
keep all personal and medical information confidential. All Shettle
Family Eye Care & Eye Wear computers are equipped with security
safeguards to also keep your information private. When insurance
claims are filed they are sent electronically through approved
clearinghouses for claims payment. Each clearinghouse and each
insurance company must also meet strict privacy and security
standards of their own.
Uses or Disclosures of Health Information
Examples of how we use information for treatment purposes:
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.
We use and disclose your health information for healthcare
operations of our office and your (and only your) insurance company.
Health care operations are those administrative and managerial
functions that we have to do in order to run our office. We may use
or disclose your health information, for example, for internal
quality assessment and improvement activities, to enable our doctors
to participate in your managed care plan, for the defense of legal
matters, to develop business plans, and for outside storage of our
records. Health care operations of your insurance company include
things such as physician review, claims payment, quality assessment,
credentialing, treatment alternatives, and fraud abuse.
Appointment Reminders
We may call to remind you of scheduled appointments. We may also
call to notify you of other treatments or services available at our
office that might help you.
Uses & Disclosures without an Authorization
In some limited situations, the law allows or requires us to use or
disclose your health information without your permission. Not all of
these situations will apply to us; some may never happen at our
office at all. Such uses or disclosures are:
A state or federal law that mandates certain health information be
reported for a specific purpose.
Public health purposes, such as contagious disease reporting,
investigation or surveillance; and notices to and from the 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, audits by Medicare or Medicaid, or
investigation of possible violations of healthcare 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 relating to workers compensation programs.
Disclosures to business associates who perform healthcare
operations for us and who agree to keep your health information
private.
Other Disclosures
We will not make any other uses or disclosures of your health
information unless you sign a written authorization form. You do not
have to sign such a form. If you do sign one, you may revoke it at
any time unless we have already acted in reliance upon it.
Your Rights Regarding Your Health Information
The law gives you many rights regarding your health information.
You have the right to restrict the disclosure of your protected
health information (in writing). The request for restriction may be
denied if the information is required for treatment, payment or
health care operations. To ask for a restriction, send a written
request to Dr. D. Scott Shettle at the address, fax or e-mail shown at the
beginning of this notice.
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. If you want to ask for confidential communications,
send a written request to Dr. D. Scott Shettle 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. You may have to pay for photocopies in advance. If you
want to review or get photocopies of your health information, send a
written request to Dr. D. Scott Shettle 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 persons 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. If you want to ask us to amend your health information,
send a written request, including your reasons for the amendment, to
Dr. D. Scott Shettle 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. 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. If you want a list, send a written
request to Dr. D. Scott Shettle 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, have copies available in our office, and post it on our
website.
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 Dr. D. Scott Shettle 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 Dr. D. Scott Shettle at the address or phone number shown at the top
of this notice.
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