Eye Care of Delaware Patient Forms
Your time is valuable, so we have made our new patient registration forms available for you to download and print.
Thoroughly complete each form at your convenience and bring them to your initial appointment. We look forward to seeing you soon for your initial evaluation.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record:
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record:
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications:
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share:
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
- We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
- We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information:
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice:
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you:
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated:
- You can complain if you feel we have violated your rights by contacting us by calling
(302) 454-8800 ext. 102 or emailing firstname.lastname@example.org
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling (877) 696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
- Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care,
and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
- We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- We can use or share your information for health research.
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date: November 17, 2022
Thank you for choosing Eye Care of Delaware, LLC and our physicians to manage your medical eye care needs. We are a medical/surgical practice and specialize in diseases of the eye. We strive to handle your visit as efficiently as possible. Your appointment may be longer than you anticipated, because our goal is to take care of your eye care needs while you are here. We can schedule separate visits for testing, if you prefer. We also treat all medical eye emergencies, which may cause a delay of your scheduled appointment.
The policy of the Practice is to provide high quality medical care in a cost-effective manner. Our professional fees have been determined through careful consideration, in addition to being reasonable and customary within our geographic area. We are pleased to discuss with you any questions you may have concerning a bill. As a courtesy to our patients, we accept multiple forms of payment, including Care Credit. The following are our Practice’s Policies.
- The patient has the right to obtain from the physician complete and current information concerning diagnosis, treatment, and prognosis in terms that the patient can be reasonably expected to understand.
- The patient has the right to privacy concerning his/her own medical care program.
- The patient has the right to receive considerate and respectful care in a safe setting.
- The patient has the right to examine and receive an explanation of his/her bill.
- The patient has the right that all disclosures and records pertaining to his/her care, will be treated as confidential and patients are given the opportunity to approve or refuse their release, except when release is required by law. The Practice operates in accordance with State and Federal records retention laws, and maintains records for seven years following the last encounter before destruction.
- If you are picking up information from our office, please be prepared to show identification. If you would like someone else to pick up something on your behalf, please arrange for prior authorization.
- Requests for records take 72 hours to prepare. We reserve the right to take up take up to 30 days, if necessary, to prepare medical records. Delaware Law authorizes our office to charge for medical records copying. All requests for medical records must be done in writing with an authorized signature.
- Please allow up to 72 business hours to process requests for medication refills. We utilize electronic prescribing.
- We consider you a patient once you have received care from one of the Eye Care of Delaware physicians. If it has been three or more years since your last visit, you are not considered to be an active patient.
- If you have someone who can translate confidential, medical and financial information to you, please make arrangements to have them accompany you on the day of your procedure. If you need a translator, please let us know prior and one will be provided. We utilize a web-based language service.
Payment in Full Is Due at the Time That Services Are Rendered
- Co-pays and co-insurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due during the check-in/out process. Failure to produce payment at check-in may result in your appointment being rescheduled.
- All CO-PAYMENTS are collected upon check-in.
- Co-insurances due may be estimated amounts. Any overpayment will be refunded upon claim adjudication and outstanding balances will be billed to the patients.
- If you receive more than one type of service on the same day, you may be responsible for multiple co-payments.
- If you see two different providers during the same day, you may be responsible for multiple co-payments. This office has providers outside of the Eye Care of Delaware that see patients and will collect their respective co-pays/insurance due.
- Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service.
- Any outstanding balance may incur a $10 monthly statement processing fee, in addition to the initial balance.
- As a courtesy to our patients, we gladly accept cash, check, money order, Visa, MasterCard, Discover, or American Express. Failure to pay balances may result in discharge from the Practice.
- All returned checks fees will become the patient’s responsibility, along with a processing fee.
- It is the patient’s responsibility to verify that the physician is currently under contract with your insurance plan and that you have obtained all necessary referrals before your scheduled appointment.
- Failure to obtain a correct referral may result in patient’s liability for all charges.
- Please inform the receptionist of any demographic changes. Failure to notify us immediately of changes in demographic information, financial status and/or insurance coverage may result in patient liability for any services not covered by your insurance carrier.
- We accept insurance information provided in good faith that it is accurate and true. If after insurance adjudication it is identified that the patient has other coverage or that insurance is no longer in effect, the patient will be responsible for payment of the service.
- Your insurance coverage and benefits are a contract between you and your insurance company and, therefore, all disputes must be handled between you and your insurance company.
- We are contracted with multiple insurers to accept assignment of benefits.
- If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a private pay patient. Additionally, out of network benefits will be utilized, if possible.
- Verification of insurance benefits require a minimum of 72 hour notice, we DO NOT guarantee coverage and benefits.
- We are required to file with your primary insurance carrier only. We will submit a claim with secondary payers. It is the patient’s responsibility to file with any tertiary payers.
- Refractive procedures are considered elective procedures; we do not submit claims for those procedures.
- We will give you an estimate of what will be due at the time of service and payment for services is due in full at the time of service.
- We will not bill insurance after the fact for private pay patients. If you elect not to have your insurance billed, the patient will sign a do not bill waiver, and you will be treated as a private pay patient. Failure to sign this waiver may result in cancellation of your appointment.
- Payment is due at the time of service, estimates will be collected at time of check-in and any additional treatment charges will be collected at check-out.
- Please make sure you have a full understanding of your benefits and what might be your responsibility, if not covered by your insurance plan.
- Medicare requires that we provide patients with a written notification, whenever it is likely that you will be responsible for a bill.
- We are not a Medicare Part A facility; the patient is responsible to be aware of those benefits. We are a Medicare Part B provider. Medicare covers services at 80% of the cost of that service.
- Patients are responsible to pay for the remaining 20% at time of service. We will collect deductibles.
- Patients who present a Medicare Card, but after claim adjudication, it is recognized that patient does not have traditional Medicare; the patient may be liable for those expenses.
Collections and Outstanding Balances
- The provider reserves the right to add a $10 monthly statement processing fee on any account that has an unpaid balance.
- Any outstanding balance after 60 days of the date of service may be referred to either a collection agency or processed for civil action. Those accounts will be subject to collection agency or attorney collection fee of 25% and/or court costs, which will be added to the total balance due.
- Patients with delinquent accounts may be discharged from our Practice.
- The parent(s) or guardian(s) accompanying a minor are responsible for providing current insurance information for the minor, as well as the payment in full for services provided.
- Parent(s) or guardian(s) must sign an Authorization for Medical Treatment form each time a minor arrives for an appointment accompanied by another adult other than their parent(s) or guardian(s).
- In compliance with HIPAA regulations, we are unable to discuss any details of services rendered or to produce an itemized bill for any parties that are not the patient, unless otherwise documented.
- Both parents/legal guardian(s) are responsible for payment for services rendered to the minor patient.
- The Practice has the right to charge a minimal fee to fill out paperwork ($5 or $10 charge, depending on the length of the paperwork).
- A minimum 72-hour notice is required for all paperwork.
- Our office will be happy to work with you in order to pay any balance due to our Practice.
- Please contact our Billing Department to work out a payment plan, if needed.
- Please allow 5 mail days for each payment to be received by our Practice.
- Refunds are issued to the appropriate party.
- Patient refunds will not be processed until all active or past due charges are paid in full.
- Refunds less than $10.00 will not be issued unless requested and will be credited to your account for future visits.
Discrimination Is Against the Law
Surgical Eye Associates of Delaware, LLC dba Eye Care of Delaware, LLC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Eye Care of Delaware, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Eye Care of Delaware, LLC:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters (Virtual Terminal)
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters (Virtual Terminal)
- Information written in other languages
If you need these services, contact the Practice Administrator.
If you believe that Eye Care of Delaware, LLC has failed to provide these devices or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
4102 Ogletown-Stanton Road, Suite 1
Newark, Delaware 19713
Phone: 302-454-8800 Fax: 302-454-1329
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Thomas Marquardt, Practice Administrator, is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Nondiscrimination statement for significant publications and signification communications that are small-size:
Surgical Eye Associates of Delaware, LLC dba Eye Care of Delaware, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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The Leading Newark Cataract and Laser Center
Eye Care of Delaware is ready to help you improve your quality of life with our specialized cataract and laser treatment options. From cataract surgery to refractive lens exchange, laser vision correction or even eyelid surgery, we are here to help. For more information, call (302) 454-8800 or request an appointment now.