This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

YOU HAVE THE RIGHT TO RECEIVE, AND WE ARE REQUIRED TO PROVIDE YOU WITH, A COPY OF THIS NOTICE OF PRIVACY PRACTICES

We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, on it's web site.

YOU HAVE THE RIGHT TO AUTHORIZE OTHER USE AND DISCLOSURE

This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses of disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOU HAVE THE RIGHT TO REQUEST AN ALTERNATIVE MEANS OF CONFIDENTIAL COMMUNICATION

This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

YOU HAVE THE RIGHT TO INSPECT AND COPY YOUR PHI

This means you may inspect, and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

YOU HAVE THE RIGHT TO REQUEST A RESTRICTION OF YOUR PHI

This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

YOU MAY HAVE THE RIGHT TO REQUEST AN AMENDMENT TO YOUR PROTECTED HEALTH INFORMATION

This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request for an amendment.

YOU HAVE THE RIGHT TO REQUEST A DISCLOSURE ACCOUNTABILITY

This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office.

YOU HAVE THE RIGHT TO RECEIVE A PRIVACY BREACH NOTICE

You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided at right, under Privacy Complaints.

Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

TREATMENT

We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your case and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

SPECIAL NOTICES

We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternative regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

PAYMENT

Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

HEALTHCARE OPERATIONS

We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

HEALTH INFORMATION ORGANIZATION

The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

TO OTHERS INVOLVED IN YOUR HEALTHCARE

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly related to that person's involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES

We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker's compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

PRIVACY COMPLAINTS

You have the right to complain to us, or directly to the Secretary of Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at:

Jackson Eye Associates, PLLC
1026 Baptist Circle, Suite 100
Madison, MS 39110

We will not retaliate against you for filing a complaint.

EFFECTIVE DATE
Sept. 23, 2013

PUBLICATION DATE
Sept. 23, 2013

Jackson Eye Associates offers interest free financing, on balances over $200, through Care Credit. Need more information? Click Here or call 800.365.8295.

PAYING FOR CATARACT SURGERY

Medicare covers surgery with a standard, or monofocal, lens implant. However, you may choose to receive a specialized lens for an added fee. Private insurance policies vary, but many also offer policy holders the choice of receiving a specialized lens as long as they pay the difference. Flexible Spending Accounts are another way you can save on your cataract surgery. For questions about any part of the payment process, please contact the billing and insurance department at Jackson Eye Associates and we will be happy to help answer any questions.

JACKSON EYE ASSOCIATES FINANCIAL POLICY

(updated 02/01/2018)

Jackson Eye Associates (JEA) is committed to providing you with the highest level of service and quality care. In order to achieve these goals, we need your assistance and understanding of our financial policy.

• PAYMENT: Payment is due in full at the time of service including copays, coinsurance and/or deductibles. If you are unable to pay these amounts in full or only make a partial payment, a $20 billing fee will be assessed to your account.

• INSURANCE CARDS: Please make sure the insurance cards presented are current and accurate. . If you have both a Medical and Vision Insurance, you must present both cards at the time of service and inform the receptionist whether your visit is medical or routine.

• INSURANCE: While JEA is happy to submit services rendered to your insurance company, for payment, ultimately you are responsible for any and all financial liabilities. JEA's office participates with most major insurance plans. JEA primarily provides MEDICAL and SURGICAL ophthalmologic care to its patients, as opposed to routine eye exams. Therefore, JEA only participates in three vision plans, Always Vision, Superior Vision, and Gilsbar Vision. NON-PARTICIPATING PLANS: If JEA Physicians do not participate in my insurance plan, I understand that I will be responsible for filing my own claims and for paying in full at the time service is rendered. TRICARE STANDARD: This insurance does not pay for routine eye exams, if your examination is found to be routine, you will need to pay in full at time of service.

• AUTHORIZATIONS: If you have a plan that requires a referral to see a specialist, you must obtain a referral in order for your visit in our office to be covered under your medical insurance. If you do not have the valid referral and still wish to be seen, you will be asked to pay for the visit prior to your examination.

• NON-COVERED SERVICES/DENIED CHARGES: Certain services may be considered non-covered services or may be denied as investigational, experimental, or not medically necessary by your insurance carrier. If your physician feels these services are needed and they are performed, you are obligated to pay for these services in full should your insurance carrier deny payment.

• REFRACTIONS: A refraction is the process of determining if there is a need for corrective eyeglasses or contact lenses. It is an essential part of an eye examination and necessary in order to write a prescription for glasses or contact lens. Most insurance plans do not cover the fee for refractions. If your insurance plan does not cover your refraction JEA will discount the refraction charge to $45 and this amount will be due at the time of service. If your plan does cover refractions you will be responsible for deductibles or coinsurance portions at the time of service.

• MEDICAID MAGNOLIA MSCAN/UHC MSCAN/CHIPS PROGRAMS: JEA participates in these programs by doctor referral only and only for medical conditions. JEA does not participate in the routine vision portion of these plans. Patients over the age of 21 who have traditional Medicaid coverage, are allotted 12 office visits annually. If you have traditional Medicaid coverage and exceed your 12 visits annually, you will be responsible for all charges. The Medicaid fiscal year is July 1st - June 30th. CHIPS (Children's Health Plan): JEA participates in the CHIPS Program for medical conditions only. JEA does not participate in the CHIPS vision plan. If you are referred by another physician and no medical diagnosis is found, you will be responsible for all charges for that visit.

• RETURNED CHECKS & PAST DUE AMOUNTS: Returned checks will be subject to collection charges, penalties and interest. All accounts are considered delinquent if not paid within 90 days of service. Past due accounts may result in collection turnover and may be subject to penalties and interest, and/or the refusal of future appointments until old balances have been paid in full. JEA does not accept postdated checks.

• CANCELLATION/”NO SHOW” POLICY: All appointments that are not cancelled within 24 hours of the appointment time are subject to a $40.00 fee. Failure to show for your scheduled appointment will also result in a $40 fee. This $40.00 fee must be paid before we can reschedule your appointment.

• SURGERY CHARGES: JEA will make every effort to notify you of an estimate of what your insurance benefits will be, prior to your scheduled surgery. Please keep in mind that this is just an estimate. Estimates of patient balances, that are not paid by due date, could result in your surgery being rescheduled or will be assessed a 10% billing fee. You may incur additional charges (in addition to the surgeon's fees) from the surgery facility, anesthesiologist, laboratory and/or radiologist. Please note: If you cancel a scheduled surgery without giving more than two (2) business days' notice, or do not show up for surgery, you will be charged a cancellation fee of $250.00. This fee must be paid prior to rescheduling.