Established Patient

Have there been any changes in your insurance?
MEDICATIONS/ GENERAL HEALTH/ ALLERGIES
Have there been ANY changes in your general health?

CONTACT LENS FITTING FEES

Contact lenses are medical devices, regulated by the FDA. This means that the doctor MUST evaluate the health of your eyes and the fit of your contacts every year in order to determine the optimum prescription for your eyes. Contact lens examinations are required on a yearly basis. These tests are done to make sure your eyes are healthy, that the lenses fit your eyes properly, and to ensure that you are seeing as clearly as possible. **There is an additional fee for a contact lens examination/fitting and prescription update. These fees are determined based on the type of lenses you are fit with. Fees range from $79.00 to $2298.00 (other specialty fits don’t apply) See Contact Lens Fitting & Evaluation for further pricing.

*Please only initial below if you're wanting contacts at today's visit*

DIGITAL RETINAL SCREENING

Dr. Carlsson has a test he highly recommends for ALL his patients. Especially, those with diabetes, hypertension, and high cholesterol. It is a digital retinal screening. He intended to use it primarily for tracking his diabetic, glaucoma and macular degeneration patients, but the Doctor feels strongly that it is important to have a baseline study on every patient. This would be extremely helpful should a condition develop in the future. The study can also reveal many developing health conditions sooner than conventional testing. The baseline procedure is $35.00.

Your insurance will not ordinarily cover the cost of the screening, but if Dr. Carlsson discovers a medical condition as a result of the study, we may bill your medical insurance. This would entail a follow up medical appointment with additional photos and an interpretation of the findings. If your insurance does not cover the billed amount or your deductible has not yet been met, you will be billed for the amount of the screening which would be $35.00.

FINANCIAL POLICY

REFUND& EXCHANGE POLICY
We have a “YES” policy within the first 30 days after dispensing glasses or contacts. Please keep in mind all products must be picked up within a timely manner after receiving communication that your product is in. Within the 30 days you are eligible for a full refund on glasses. A full refund will be granted for contacts as long as the product is unopened and/or damaged. Choosing a different frame is also warranted in this time period. The credit will go towards your new frame. After, the 30 day time period a restocking fee of $150.00 will be issued on any product being returned. A doctor’s change is allowed within 60 days of dispensing. After, the 60 days if there is no documentation or attempt to correct the situation no prescription change will be granted.
LIMITS OF INSURANCE COVERAGE AND ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
Our Doctors and staff are dedicated to assisting you in making sure that your health insurance will reimburse for all covered services. Your health insurance and vision rider may not pay for all of your health care costs; your employer and your insurance company largely determine your health care benefits. Health insurance only pays for covered items and services when their rules are met.
INSURANCE COVERAGE
It is your responsibility to be aware of your insurance coverage policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. We must verify that your health and vision coverage are valid before the date of your visit. It is your responsibility to provide us with accurate information to accomplish this, including your insurance card numbers and social security number if needed. No coverage will be accepted after services are rendered.

We will make every effort to verify your coverage prior to your visit. The benefits given are an estimate only. Any difference after the claim has been processed will be your responsibility.
CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES
Co-payments, co-insurance and deductibles are the responsibility of the patient/guardian and are due at the time of the visit. These are determined by the contract you have with your insurance carrier.
REFERRALS
If your plan requires, it is your responsibility to obtain referrals from your Primary Care Physician prior to your visit.
INSURANCE REQUESTS
You are responsible for responding to insurance company requests for further information. Failure to respond to your insurance company’s requests will result in denial of the claim and will make you responsible for payment
VISION COVERAGE
Vision riders, which have a limited benefit, may only be used for visits that are strictly vision related. Any visit that is of a medical nature must be billed to the medical insurance.
REFRACTION
Some medical insurers will not pay for refraction (the act of finding the glasses prescription). If your carrier is one of these you may be asked to pay for that service.

I have read and understand the terms of this Financial Responsibility form.
Have been provided a copy of Carlsson Family Eye Center’s Notice of Privacy Practices and I have had an opportunity to read the Notice.

CANCELLATIONS/RESCHEDULING
A 48-hour notice of cancellation or rescheduling of an appointment is required. Changes made without a 48-hour notice may be subject to a $45 charge.

I have read and understand the terms of this Financial Responsibility form.

ACKNOWLEDGEMENT OF PRIVACY POLICY

(Patient’s Printed Name)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.
Your “health information,” for purpose of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to a ‘’health information’ in this Notice).
We are required by Health Insurance Portability and Accountability Act of 1996 (“HIPAA’’) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of the notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.
USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION
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 purpose are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; 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 manage care plans; defense of legal matters; business planning; and outside storage of our records.

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT
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 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 of Medicaid; or for investigation of possible violations of health care laws;
• disclosures for judicial and administrative proceedings, such as in response to subpoenas or order 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 out office; or to report a crime that happened somewhere else;
• disclosures 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;
• use and disclosures to prevent a serious threat to health or safely’
• use or disclosures for specialized government functions, such as for the protection of the president or high ranking government official; for lawful national intelligence activities; for military purpose; 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;
• [Specify other uses and disclosures affected by state law].

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.
SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION
The following are some specific uses and disclosure 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 form 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 note on our patients, we are required to notify you that we generally must obtain your authorization prior to using or disclosing any such notes.
YOUR RIGHTS TO PROVIDE AN AUTHORIZATION OTHER USES AND DISCLOSURES
• Other uses and disclosures of your health information that are not descried 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 discourse of your health information to a health plan if the disclosure is f or 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 disclosure 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 your prior to the date you revoked your authorization.

YOUR INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:
• 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 retractions, please send a written request to us at the address below.
• 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. I f 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 nor in writing or does not provide a reason to support your request. We may also deny your request if the health information:
o Was not created by us, unless the person that created the information Is no longer available to make the amendment,
o Is not part of the health information kept by or for us,
o Is not part of the information you would be permitted to inspect or copy, or
o 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 April 14, 2003. 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.

Contact Person:
Our contact person for all questions, requests or for further information related to the privacy of your health information is: Anne Carlsson 480-988-4131

Name Address
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 the office contact person at the address, fax or E mail shown above. If you prefer, you can discuss your complaint in person or by phone.
Changes to This Notice:
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.

Sidebar Links

A very pleasant office, staff and experience purchasing eyewear. Very professional yet personal service. My daughter and I have been going to Carlsson Family Eye Center for several years.

-Very pleasant office,
Anonymous

Dr. Carlsson is a concerned and thorough eye doctor. He has a competent and friendly staff. We feel comfortable in returning to him for continued eye care.

-Concerned and thorough,
James Visger

I would definitely recommend Carlsson Family Eye Center to friends and family! The staff was very helpful and kind. This was my 3 & 4 year olds first eye exam and Dr. Carlsson made them feel comfortable and was very patient with them. Overall it was a great experience and we certainly be returning.

-Helpful and kind,
Reese Wildey

Dr. Carlsson ia awesome! He discovered that my child had the incorrect prescription for over a year! He corrected the previous Dr.’s error and set her up with new glasses. Thank you!

-He corrected the previous Dr.'s error,
Jaeden Batista

Dr Carlsson took the time needed and listed to the history of my son and daughter. He is very patient dealing with children which I appreciate

-Very patient dealing with children,
Anderson Shimkus

Everyone was so nice and helpful! Dr. Carlsson was amazing with my very shy 4 year old. I live 40 miles away from the office but I won’t go anywhere else, they are that amazing! We found our family eye doctor!

-Amazing with my shy 4 year old,
Maddison Jacques

The office staff was friendly and helpful. My appointment was on time, no waiting. Dr. Carlsson was thorough on my exam and helpful in finding what would best suit my eye-changing needs. Laura, helped me pick out frames and was super sweet to work with. The office is clean and also has a kid’s area where my children hung out during my appointment.

-Friendly and Helpful,
Dorothy Guymon

My whole family sees Dr Carlsson. All of his staff are very friendly. Dr Carlsson is great with the kids and very knowledgeable.

-My whole family sees Dr Carlsson,
Jacqueline Wedding

The entire staff is excellent. I was greeted nicely and treated excellent throughout my entire appointment. Dr. Carlsson took the time to explain and give me options. His assistants did the same. If you are looking for great service, friendly staff, and a great selection of eye ware, please see Carlsson Family Eye Care.

-Excellent,
Savanaha Luper

It’s nice to find a family-owned optometrist in Gilbert. They give you more of a personal touch than a chain does.

-Carol A.
Chandler, AZ

-Visitor,
A Good Family-Owned Optometrist in Gilbert

I have been very impressed with the Carlsson team. I got a good deal on a comprehensive eye exam, as well as two pairs of designer frames, and some disposable contact lenses. I’ve found my eye doctor in Gilbert.

-Ryan G.

-Satisfied Customer,
Mesa, AZ