PATIENT FORMS

We Promote Safe and Healthy Contact Lens Wear!

Our doctors and staff are skilled contact lens fitting specialists with careful attention to education regarding appropriate lens hygiene and replacement schedules. Fitting Evaluations are available for patients of all ages and while we cannot guarantee that your first attempt at mastering the insertion and removal of contact lenses will be successful, our goal is to provide the time and patience you require to see you succeed if you desire. Proper assessment of your vision correction needs is what ensures our success rate in finding a lens type that works long-term for you. In the state of Washington, your contact lens prescription is valid for two years with an annual eye health examination recommended to ensure the safety and health of your vision as a contact lens wearer.

The Eye Clinic of Edmonds is stocked with a wide variety of trial contact lenses from Daily to Multifocal varieties and we sample nearly a dozen different cleaning and storing solutions, sure to be compatible with your lens type. Ordering your lens supply is a snap with FREE SHIPPING to your home or office available on all orders of a year supply or more. and we will gladly bill your insurance if your vision materials benefit includes contact lenses. Below you will find our official Contact Lens Form which details our Fitting Evaluation Fees and information on the recommended practices for contact lens use. Please be sure to review and sign this form each time we see you for an update to your contact lens prescription or for an initial fitting evaluation. The following form is also attached to our print out of the Registration Documents or from the front desk upon checking in for your appointment. Thank you!

Note: This Notice of Privacy Practices is provided for educational and informational purposes only. This Notice is not intended as legal advice, and is not provided for adoption or publication by any party. The publication of any such notice may create legal obligations or liabilities which may vary depending upon the legal status and business operations of different organizations. The form and content of any Notice of Privacy Practices should be determined only upon informed consultation with qualified legal counsel.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.

Right to Notice As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Eye Clinic of Edmonds can use your protected health information for treatment, payment and health care operations. a) Treatment – We may use or disclose your health information to a physician or other health care provider providing treatment to you. b) Payment – We may use and disclose your health information to obtain payment for services we provide you. c) Health care operations – We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competency or qualifications of health care professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.

Emergency Situations In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person’s involvement in your health care.

Marketing We will not use your health information for marketing communications without your written authorization.

Required by Law We may also use or disclose your health information when we are required to do so by law.

Abuse or Neglect We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people’s health or safety.

National Security We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.

Appointment Reminders We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.

Your Rights as a Patient 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. -You have the right to receive confidential communications regarding your protected health information. -You have the right to inspect and copy your protected health information. -You have the right to amend your protected health information. -You have the right to receive an account of disclosures of your protected health information. -You have the right to a paper copy of this notice of privacy practices.

Legal Requirements Eye Clinic of Edmonds is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this site, or are available within our office.

Complaints If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.

Contact Information For further information about the Eye Clinic of Edmonds’ privacy policies, please contact Deborah Jarboe, at the following address or phone number: Eye Clinic of Edmonds 21911 76th Ave. W. #101 Edmonds, WA 98026-7512 425-774-7723