FOR YOUR Information 2800 THIRD STREET • RAPID CITY, SD 57701 WWW.BLACKHILLSEYES.COM
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FOR YOUR Information2800 THIRD STREET • RAPID CITY, SD 57701
WWW.BLACKHILLSEYES.COM
VISION FOR LIFESpecialties Of The Eye Institute
iLASIK & PRK Surgery • Cataract SurgeryCornea • Glaucoma • Diabetic Retinopathy
Macular Degeneration Wet & DryGeneral Eye Exams
Ophthalmic Plastic and Reconstructive SurgeryFDA Clinical Trials
605-341-2000 / 2800 Third St Rapid City, SD 57701 / www.BlackHillsEyes.com
We are
Prema Abraham, MD Stephen Khachikian, MD
Ryan Scarborough, OD
Terrence Spencer, MD
Jess Moser, OD
Adam Jorgensen, MD
Scott Schirber, OD
WelcomeWelcome to the Black Hills Regional Eye Institute and thank you forselecting our facility to serve your eye health care needs. We will doall we can to provide you the very best of care. Your physician would
like you to review this patient infom1ation booklet. If there arequestions that you have that might not be answered in this booklet,
please do not hesitate to a ask any of the Institute staff. It is our desireto make your visit both as pleasant and as beneficial as possible.
Please keep this booklet for future reference.
Appointment
For: _____________________________________
Date: ____________________________________
Time: ____________________________________
Dr. ______________________________________
Please advise the person at the registration counter when you arrive of any change in your address, phone number, insurance,
etc., that has occurred since your last visit.
1st Floor – Check-In for Doctors Jorgensen, Khachikian, Moser, Scarborough, Schirber, Spencer iLASIK Center
2nd Floor – Surgery Center & Check-In
3rd Floor – Dr. Prema Abraham & Check-In Dr. Bucknall & Low Vision Center Clinical Trials & Research Offices Administrative Offices
Any patient requiring assistance transferring will need to be accompanied by someone who can aid in that transfer.
On-Line Patient Registration & Secure E-Mail Messaging
Save time at your check-in and register online before your appointment! It’s easy as 1-2-3
1. Go online to www.blackhillseyes.com
2. Click this logo on our home page for the link to register:
3. Set-up a secure on-line account by completing the questionnaire. Completion of your online registration will allow you to send us a secure email message. You will now be able to view your medical record online.
Setting up this account will allow you to send secure email messaging to submit follow-up questions, medicine changes, or post-op questions to your doctor. It’s secure and convenient and available 24/7, plus you can expect a response from us
within 24 hours.
NO SMOKING PLEASEFor your health, the health of your fellow patients and the staff of the Institute, there is no smoking allowed on the Black Hills Regional Eye Institute grounds.
At The Eye InstituteOn your first visit to the Black Hills Regional Eye Institute you will be asked to fill out an information form and to answer some basic questions concerning your medical history.
This information is a necessary, so the doctor can take a quick glance and obtain essential data about you. Your address and phone number are needed in case a doctor writes a prescription for you or needs to contact you.
Information concerning your occupation, age, etc., is likewise important, for it has bearing upon your health, physical condition, and how your sight may be affected. We will also ask for your social security number. This information is used to file an insurance claim with various carriers or to establish an account that could carry a balance. If we do not obtain your social security number, your account will be self-pay, and we will not be able to submit your claim to insurance.
Also during the check-in process, we will ask to see a photo ID. In order to protect you against fraudulent use of your identity and your insurance by others, we ask to see a photo ID. At that time, we will take a photo to include in your patient chart so that you won't be required to show your photo ID at subsequent visits.
All of the information requested is necessary and considered confidential.
The Black Hills Regional Eye Institute operates on the principle that the patient is the most important person in the Institute. And that the patient's care, both medically and personally, is the primary concern of the Institute's staff. The Institute's most important goal is to provide the highest possible quality eye care through its facility to the residents of the geographic region.
An ophthalmologist is an M.D., who specializes in the diagnosis and treatment of the eye. There are a number of ophthalmologists practicing at the Black Hills Regional Eye Institute whose purpose is to provide the highest quality and the most comprehensive eye care that is available anywhere in the country today.
This care ranges from complete routine eye examinations to the most complicated of eye surgeries. The receptionist will assist you in determining which physician's secretary you should talk to for an appointment depending on your particular eye care or scheduling needs.
The Eye Institute provides the latest and most sophisticated equipment available for evaluation and treatment of the eyes. Each physician has had extensive training in all areas of eye care and have, as well, areas of special expertise. The areas of sub-specialization within the field of ophthalmology offered at the Institute include, retinal disease, macula and vitreous, diabetic retinopathy, plastic surgery, glaucoma, laser surgery, iLASIK - laser vision correction, cornea surgery, cataracts and implants.
The Black Hills Regional Eye Surgery Center The Surgery Center located on the second level of the Institute. This is a modern and efficient ambulatory surgery center that allows the Institute's patients to have outpatient eye surgery in a warm and friendly atmosphere.
The facility was specially designed for eye surgery. It is licensed under the State of South Dakota and is certified by the U.S. Health Care Finance Administration for use by Medicare patients.
Doctor ServicesIn addition to routine eye exams, our doctors provide a wide range of services for your ocular health.
Look to Dr. Prema Abraham, Director of The Retina Center at the Eye Institute, for medical and surgical management of diseases of the retina, macula, and vitreous. This includes "cutting edge" treatments for macular degeneration, including visudyne photodynamic therapy, transpupillary thermotherapy, and feeder vessel treatment. Additionally, Dr. Abraham is involved in the latest national clinical trials for both diabetic retinopathy and macular degeneration and fellowship trained in retina. She offers appointments in Rapid City and Pierre.
Dr. Adam Jorgensen is fellowship-trained in surgical glaucoma; he will also provide medical and surgical management of, cataracts and general ophthalmology at the Eye Institute.
Dr. Stephen Khachikian is fellowship trained in cornea and refractive surgery and provides services in cataract surgery, cornea surgery including transplants, and refractive surgery including iLASIK. You can schedule an appointment with Dr. Khachikian in Rapid City, one of his Northern Hills satellite clinics, or in Gillette, WY.
Dr. Scott Schirber serves as the clinical director for the Laser Vision Center. He brings a wealth of experience having managed thousands of refractive surgery patients and sees patients in Rapid City and Gillette, WY.
Dr. Terrence Spencer provides topical clear cornea cataract surgery and refractive surgery, including iLASIK. Dr. Spencer provides services in Rapid City, Sturgis, Pierre, and Huron. He is fellowship trained in Ophthalmic Pathology and Intraocular Lens Research.
Laser Vision CorrectionDid you know the Black Hills Regional Eye Institute Laser Vision Center was the first to perform LASIK in the Black Hills region and continues to be your leader in vision correction procedures? You can feel confident with our team of Dr. Stephen Khachikian, Dr. Terry Spencer, and Dr. Scott Schirber. We have the finest technology available today, and the Eye Institute is the only center in the region to offer iLASIK. It combines the IntraLase laser to create the flap, Iris Registration to track movement of the eye, and VISX CustomVue to provide a personalized custom treatment. Custom LASIK provides better night vision, a better quality of vision and better safety, a true advantage in laser vision correction. For your convenience, we also work closely with your family eye doctor to ensure that you receive the finest care possible before and after surgery.
Take the iLASIK self-test online at www.LasikRapidCity.com or call 605-718-3937 to schedule your free consult.
HoursThe Black Hills Regional Eye Institute is normally open from 8:00am to 5:00pm on Monday through Friday. The Institute is closed on the following holidays: New Year's Day, Memorial Day, July the Fourth, Labor Day, Thanksgiving Day and Christmas.
After hours and on the weekend, the answering service will take information and locate the doctor on call in case of an emergency. When the Institute is not open, it is best to go
to the nearest hospital when a true emergency occurs. The physician on duty will begin treatment and will contact one of the ophthalmologists if necessary.
The best way for a physician to remain well informed about the most recent and effective methods of diagnosis and treatment is for him/her to attend medical conferences in his specialty. If a particular doctor that you are trying to reach is at a medical meeting or is unavailable for other reasons, then your call to the Institute or the answering service will be referred to another of our well-qualified ophthalmologists.
Satellite ClinicsWe understand that not everyone can come to our Rapid City office for an eye exam. That's why we offer satellite locations throughout South Dakota and Wyoming. The Black Hills Regional Eye Institute is dedicated to making eye care convenient and affordable to all members of our region.
AppointmentsOut of necessity, the doctors must work by appointment. This gives them an opportunity to allocate their time and proves to be more convenient for the patient. Unfortunately, emergencies do occur, and occasionally delays in scheduling can occur. Emergencies will be seen and worked in with the regular appointments as necessary. A sincere attempt is made to adhere to the schedule as much as possible. If we are significantly delayed, we will try to notify you beforehand. Please assist us by being on time for your appointment.
The further in advance the patient can call to set up an appointment, the better the chance of making an appointment best suited to the patient's convenience.
Please do not ask that other members of the family be worked in
when you arrive at the Institute for your scheduled appointment. This would make adherence to a schedule difficult and would not be fair to the other patients with scheduled appointments.
Eye appointments are of two types: COMPLETE EXAMS or first visits may take one to two hours, so please allow ample time. TREATMENT or FOLLOW-UP examinations require thirty to sixty minutes.
Sometimes eye drops are used in the examinations, which may briefly blur your vision and make your eyes sensitive to light. Plan your visit accordingly and arrange for someone to drive you home, if possible. Bring sunglasses if you have them. Also, please bring your glasses with you, even if they are broken or unsatisfactory.
Cancellation Of AppointmentsIf you are unable to keep your scheduled appointment or will be late, please notify the Institute as soon as possible for rescheduling. This courtesy allows us to be of service to other patients.
The Young PatientWe like children and derive a great deal of pleasure from helping them. Parents can be a great aid in establishing a good doctor-patient relationship by preparing their children for the coming visit to the doctor. Children have a remarkable ability to adapt themselves to new situations providing they are prepared for what is to be expected. The visit should be treated in a matter-of-fact manner as part of the routine of his or her young life.
Every precaution is taken to avoid causing the young patient any discomfort. We try to cooperate with the child as much as possible. The major causes for a child protesting examination are when the lids are examined, or a bright light is shined in the eye, or eye drops are administered. There is no pain from the above, but the child may consider it an imposition.
Please do not bring other children in the family unless absolutely necessary. The young patient deserves privacy when at the doctor's office just as much as does the adult. Having other children observe the proceedings will increase the patient's apprehension, hamper the examination, and hamper the treatment.
Telephone CallsFor the doctor to leave a patient being examined to answer every office phone call would obviously be unfair to the patient under treatment and the patients waiting for examination. The Institute staff has been trained to answer most questions. However, if they are unable to answer your questions, your chart will be obtained, and your call will be returned.
Please remember that many diseases have the same symptoms and require specialized equipment to diagnose. For this reason, most requests for treatment will require an office examination.
After hours and on weekends an answering service is available in case of an emergency.
Anesthesia, X-Rays and Laboratory WorkAll anesthesia, laboratory studies, and X-Rays will be referred to an anesthesiologist, a nurse anesthetist, pathologist, or radiologist. You will be billed for these services separately from the physician or surgeon.
FeesThe fees charged in the Black Hills Regional Eye Institute reflect the many years of medical and surgical training, specialized equipment, and time required to provide complete eye care.
In order to keep the increasing costs of delivering health care down, the Institute works on a cash basis. We prefer not to send bills because the cost to do this affects our fees. We would appreciate it if you would be prepared to pay for your examination at the time you are seen. If financial problems arise, please let us know. We will be happy to make arrangements that are mutually agreeable. Eye care and the restoration of vision is our utmost concern for our patients. We urge patients to freely discuss financial matters with us so we can work together in handling any problems.
If elective (non-emergency) surgery is planned, you and your family are invited to discuss the fees and suggest methods of payment. An estimated charge for any uncomplicated surgery will be given which includes a specified period of post-operative care for similar operations. This fee doesn't include unexpected complications, unrelated conditions, or secondary procedures.
In order to maintain a continuity of eye care, fifty percent of the total fee is required prior to an elective surgical procedure. All patients referred by an ophthalmologist or optometrist for eye surgery will be asked to return to their referring doctor for glasses and contact lenses if needed.
Insurance and MedicareInsurance companies have a schedule of amounts they will pay for the care you receive. Your physician's fees may be more or less than these amounts allowed by your insurance company. You are personally responsible for your account, irrespective of your insurance company's payment schedule. All deductibles, co-insurance/co-pays, and fees for non-covered services are due at the time of service. Surgery charges and payment will be discussed with you prior to the surgery date. Fifty percent of the total fee for an elective surgical procedure is due at the time of service. Please inform us of any pre-authorization
requirements of your insurance company.
For Medicare payments, the Institute will submit your claim to Medicare. All we will need is your Medicare number. For other insurance carriers, the patient has the responsibility. However, we will be happy to file the insurance claims for you as a courtesy. When obtaining your insurance information, we will also ask for your social security number. This information is used to file an insurance claim with various carriers or to establish an account that could carry a balance. If we do not obtain your social security number, your account will be self-pay, and we will not be able to submit your claim to insurance.
Again, if unusual circumstances should make it impossible for you to pay while at the Institute, we invite you to call or personally discuss the matter with our patient account staff. This will avoid misunderstandings and enable you to keep your account in good standing.
Please be sure to bring all of the necessary forms and insurance information with you to the Institute.
Red Flag RulesIt is the policy of the Black Hills Regional Eye Institute to follow all federal and states laws and reporting requirements regarding identity theft. The Eye Institute staff will be alert for discrepancies in documents and patient information that suggest risk of identity theft or fraud. The Eye Institute will verify patient identity, address and insurance coverage at the time of patient registration/check-in. The verification will be done as follows: The patient will be asked to bring the following at the time of the appointment: driver's license or other photo ID; current health insurance card; and if the photo ID does not show the patient's current address - the patient will be asked to bring utility bills or other proof of residence. This requirement may be waived for patients who have visited
the practice within the last six months - where a photo of the patient has been taken at time of check-in.
Low Vision CenterA Low Vision Center is located on the third floor of the Eye Institute. Low vision aids such as voice enhanced devices, large print items, magnifiers and closed captioned TV's are available for purchase. Low vision exams can also be scheduled with Dr. Bucknall. The center is operated by an outside organization and has limited hours of operation, so please call 605-718-2303 for store hours.
Black Hills Regional Eye Institute, LLP Black Hills Regional Eye Surgery Center, LLC
Black Hills Regional Refractive Eye Surgery Center, LLC 2800 Third Street, Rapid City, SD 57701. 605-341-2000
REQUIREMENTS FOR YOUR APPOINTMENT
We are committed to providing patients with the highest level of service and quality care. If you have medical insurance, we will strive to help you receive your maximum allowable benefits, in order to do this we need your help to understand the following information before your appointment.
• Photo ID: Federal Law requires proof of identity to submit to an insurance carrier. If unable to provide a photo ID, Patient will be required to pay for services upfront.
• Current information: Bring all current insurance cards and provide current demographic information including address, phone numbers and employer.
• Social Security Number: We require the social security number of the responsible party to establish an account that carries any balance. If you do not wish to supply your social security number, we are happy to provide your medical care, however, we will require you to pay for all service in full prior to being seen.
• Managed Care or PCP (primary care provider) plans: If your insurance requires a referral to see a specialist, you must obtain that referral to have insurance process your visit. If you do not have a valid referral you will need to pay for the visit prior to being seen.
• Prior Authorizations: Some insurance plans require a prior authorization for services by a specialist. Review your policy to see if there is such a requirement. Our office will be happy to assist you in obtaining prior authorizations or approvals when needed, but remember it is your responsibility to know the requirements of your policy. Failure to obtain prior approval or prior authorization could result in a service being non-covered, which will result in higher out of pocket costs for you.
• Co-pay and Deductibles: Patients are responsible to know what their co-pays and deductibles are. It is also your obligation to pay these co-pays and remaining deductibles at the time of service. If a patient has a question regarding their payment requirements they should contact our medical billing staff PRIOR to services being rendered.
• Payment Due: Payment is considered due when services are rendered. We file to your medical insurance as a courtesy.
• Payment Arrangements: As outlined above, co-pays and any remaining deductibles are due at time of service. Patients may also have co-insurance for services rendered; if they are unable to pay the co-insurance amounts within 90 days they should contact the medical billing department to discuss possible alternative payment arrangements.
• Refractions: 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. Medicare and most medical insurance do not cover the fee for refractions. You are responsible for this fee and it is payable at the time of service. We can, at your request, file your refraction charge with your medical insurance plan. If your insurance policy pays this fee, we will then refund your payment.
• Participating Insurance Plans: Our office participates with several insurance plans. It is your responsibility to verify with your insurance company if our office is within your networks.
• Vision Plans: Our office does not participate with any Routine Vision Plans such as VSP, Davis Vision, etc.
• Medical Plans that have Vision Benefits: Please be advised that some medical plans do have routine vision benefits; however, sometimes these vision benefits are with a different carrier than your medical plan. We may be participating providers with your medical plan but not your vision plan. Please contact your carrier to verify your benefits and whether the practice is a provider for both your medical and vision plan.
• Non-covered Services: Patients understand that some services may be considered non-covered by their insurance plans. The patient is responsible to know what their insurance does or does not cover and understand that they are financially responsible for paying all non-covered services.
• Minors: For all services rendered to minor/dependent patients, we will look to the parent or legal guardian accompanying the patient for payment. In cases of separation or divorce, when presenting insurance cards for a dependent enrolled under a subscriber other than you, please be prepared to supply that subscriber’s name,
address, phone number, date of birth. We request that you inform the subscriber that their insurance has been used.
• Denied Charges: Our physician may recommend treatment for services that are denied as investigational, experimental or not medically necessary by insurance plans. Patients are still obligated when applicable to pay for these services in full.
• Finance Charges: The current rate is 24% APR and is automatically applied to all accounts with a balance over 90 days.
• Past Due Accounts: All accounts are considered past due if not paid within 90 days of service. Past due accounts without acceptable current payment arrangements may end up being referred to an outside agency for collection, which can be subject to penalties and interest, or the inability to be scheduled for future appointments until old balances have been paid in full.
• Surgery Charges: The practice will make every effort to determine your insurance benefits and to relay your estimated responsibility for the surgery charges. Keep in mind that this is just an estimate and when surgery is performed, you may incur additional charges from the surgeon, surgery facility, anesthesiologist, laboratory or radiologist.
• Form Completions: There may be charges for completing various forms, including DMV, AFLAC, or disability forms. When appropriate pre-payment would be required for completing these forms or for extra written communication by the doctor. The charge is determined by the complexity of the form, letter, or communication.
• Surgical Cancellations: Any patient who cancels a scheduled surgery without giving more than two (2) business days’ prior notice, or does not show up
for a scheduled surgery, may be charged a $200.00 rescheduling fee. Legitimate emergencies will be taken into consideration.
• Payment Types: We accept the following forms of payment: Cash, Personal Check (seven days prior, when for refractive upgrades), Visa, MasterCard, Discover, Money Orders, Cashier Checks, or Bank Checks. We also accept Care Credit ONLY for uninsured patients, Lasik, refractive upgrades, or cosmetic procedures. We do not accept American Express.
We provide MEDICAL and SURGICAL ophthalmologic care to our patients; in addition to our medical surgical care we offer routine eye exams with our Optometrist.
It is the patient’s/parent’s/guardian’s responsibility to understand or ask questions regarding the information stated above. Ultimately, all financial liability rests with the patient. Should you have any questions about our financial policies, please contact one of our medical billing specialists prior to your scheduled appointment at 605-341-9120 or 1-800-658-3500.
Effective 3-14-2018
Black Hills Regional Eye Institute, LLP Black Hills Regional Eye Surgery Center, LLC
Black Hills Regional Refractive Eye Surgery Center, LLC 2800 Third Street, Rapid City, SD 57701.
605-341-2000
PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES
Patients, Patients Representatives or Surrogates have the right to…
• Be informed of their rights and responsibilities.• Receive treatment and medical services without any type of discrimination.• Be treated with consideration, respect and recognition of their individuality; be informed of the names and functions of all physicians and other healthcare professionals providing their direct care. • Receive the services of a translator or interpreter to facilitate the communication between the patient and the facility’s healthcare professionals.• Participate in the development and implementation of their plan of care.• Make informed decisions regarding their care.• Be informed of their health status, involved in care planning and treatment, and allowed to request or refuse treatment.
• Be included or to refuse to be included in experimental research.• Have a full explanation if they are being transferred to another facility.• Be informed if the facility has authorized other institutions to participate in their treatment. Patients have the right to know the identity and function of these institutions, and to refuse to allow the institutions to participate in their treatment.• Formulate advance directives and have physicians and other healthcare professionals comply with these directives. • Be informed by their physician and other healthcare professionals about any continuing healthcare requirements after their discharge.• Receive assistance from their physician and appropriate healthcare professionals in arranging for required follow-up care.• Have their medical records kept confidential.• Have access to their medical records within a reasonable time frame.• Be free from restraints of any form that are not medically necessary.• Be free from all forms of abuse and harassment.• Receive care in a safe setting.• Examine and receive an explanation of their bill and may receive information relating to financial assistance available.• Be informed in writing about the facility’s policies and procedures for initiation, review and resolution of patient complaints, including the address and telephone number of where to file complaints with the Department of Health and Human Services. • Provide a responsible adult to transport you to and from the ESC remaining with you for 24 hours
Patients, Patients Representatives or Surrogates have the Responsibility to…
• Provide complete and accurate information including your full name, address, home telephone number, date of birth, Social Security number, insurance carrier and employer when it is required. • Provide complete and accurate information about your health and medical history, including present condition, past illnesses, hospital stays, medicines, vitamins, and any other matters that pertain to your health, including perceived safety risks. • Ask questions when you do not understand information or instructions. If you believe you cannot follow through with your treatment plan, you are responsible for telling your doctor. You are responsible for outcomes if you do not follow the care, treatment, and service plan.• Treat all facility staff, other patients, and visitors with courtesy and respect; abide by all facility rules and safety regulations; and be mindful of noise levels, privacy and number of visitors.• Provide complete and accurate information about your health insurance coverage and to pay your bills in a timely manner.• Keep appointments, be on time and call your health care provider if you cannot keep your appointment.
Patient Grievance Process
During your stay, if you have comments, questions or concerns that have not been addressed, or if you think you are being prematurely discharged, please ask to speak with a manager, and your caregiver will contact someone immediately.
To file a written comment, question or concern with our facility, you may write to:
Black Hills Regional Eye InstituteAttn: Administrative Assistant
2800 Third StreetRapid City, SD 57701
Comments, questions or concerns to this facility will be addressed within seven business days.
At any time, you, your representative, or your surrogate may contact the South Dakota Department of Health at:
Complaint CoordinatorSouth Dakota Department of Health
Licensure & Certifications615 East 4th StreetPierre, SD 57501
Or Call: 605-773-3356
Medicare beneficiaries may contact the Website for the Office of the Medicare Beneficiary Ombudsman at:
http://www.cmshhs.gov/ombudsman/recources.asp
to ensure that Medicare beneficiaries receive the information and help they need to understand their Medicare rights and protections.
Black Hills Regional Eye Institute, LLP Black Hills Regional Eye Surgery Center, LLC
Black Hills Regional Refractive Eye Surgery Center, LLC 2800 Third Street, Rapid City, SD 57701.
605-341-2000
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION
During your treatment at the Eye Institute, doctors, nurses, technicians, and other caregivers may gather information about your medical history and your current health. This notice will explain how such information may be used and shared with others. It will also explain your privacy rights regarding this kind of information.
Your medical information will be used and disclosed for the following purposes:
TREATMENT: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
PAYMENT: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
HEALTH CARE OPERATIONS: Your health information may be used as necessary to support the day-to-day activities and management of the Eye Institute. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
LAW ENFORCEMENT: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting.
PUBLIC HEALTH REPORTING: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.RESEARCH: Your health information may be used and disclosed for research purposes.
VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE: In certain circumstances, covered entities may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
HEALTH OVERSIGHT ACTIVITIES: Covered entities may disclose protected health information to health oversight agencies for purposes of legally authorized health oversight activities, such as audits and investigations necessary for
oversight of the health care system and government benefit programs.
ESSENTIAL GOVERNMENT FUNCTIONS: Your health information may be disclosed for certain essential government functions, including assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, determining eligibility for or conducting enrollment in certain government benefit programs, and determining eligibility for military service.
WORKERS’ COMPENSATION: Your health information may be disclosed as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses.
OTHER USES & DISCLOSURES REQUIRE YOUR AUTHORIZATION: Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Additional Uses of InformationAPPOINTMENT REMINDERS: Your health information will be used by our staff to send you appointment reminders.
Information About Treatments & Health Related Services:
Your health information may be used to send you information
that you may find interesting on the treatment and management of your medical conditions. The Eye Institute may also send you information about your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.
Individual RightsYou have certain rights under the federal privacy standards. These include: • The right to request restrictions on the use and disclosure of your protected health information. • The right to receive confidential communications concerning your medical condition and treatment. • The right to inspect and copy your protected health information. • The right to receive an electronic copy of your protected health information. • The right to amend or submit corrections to your protected health information. • The right to receive an accounting of how and to whom your protected health information has been disclosed. • The right to add and/or revoke authorization to individuals designated to be allowed access to your PHI.
The Black Hills Regional Eye Institute DutiesWe are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. We will notify you in the event of a breach of protected health information.
RIGHT TO REVISE PRIVACY PRACTICES: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations.
Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION: You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Eye Institutes's Privacy Official. Your request will be reviewed and generally be approved unless there are legal or medical reasons to deny the request.
COMPLAINTS AND CONTACT PERSON: If you would like to submit a comment or complaint about our privacy practices, need further information concerning our privacy practices, or if you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter outlining your concerns to the Privacy Officer:
Visit our website atwww.blackhillseyes.com
to view our non-discrimination notice
Effective Date: This notice is effective on or after April 14, 2003. Amended: This notice was amended on September 16, 2013 and April 13, 2015.
Black Hills Regional Eye Institute2800 Third Street
Rapid City SD 57701
At The Eye Institute
some basic questions concerning your medical history.
This information is a necessary, so the doctor can take a quick glance and obtain essential data about you. Your address and phone number are needed in case a doctor writes a prescription for you or needs to contact you.
Information concerning your occupation, age, etc., is likewise important, for it has bearing upon your health, physical condition, and how your sight may be affected. We will also ask for your social security number. This information is used
an account that could carry a balance. If we do not obtain your social security number, your account will be self-pay, and we will not be able to submit your claim to insurance.
Also during the check-in process, we will ask to see a photo ID. In order to protect you against fraudulent use of your identity and your insurance by others, we ask to see a photo ID. At that time, we will take a photo to include in your patient chart so that you won't be required to show your photo ID at subsequent visits.
All of the information requested is necessary and considered
The Black Hills Regional Eye Institute operates on the principle that the patient is the most important person in the Institute. And that the patient's care, both medically and personally, is the primary concern of the Institute's staff. The Institute's most important goal is to provide the highest possible quality eye care through its facility to the residents of the geographic region.
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(605) 348-8300 Or (855) 732-3622Located Only 2 miles from BHREI
AMERICAS BEST VALUE INN620 Howard Street
Exit 58 near Applebee’s and Chili’s(605) 343-5434 Or (888) 315-2378
ALEX JOHNSON HOTEL523 6th Street
(605) 342-1210 or 1(800) 888-2539
CAMBRIA SUITES
(605) 341-0101Located off I-90 next to Cabela’s. Free Shuttle service available
COMFORT INN & SUITES915 Fairmont Blvd
(605) 718-4444
RAMKOTA HOTEL2111 N. LaCrosse St.
(605) 343-8550 or 1(800) 528-1234
RUSHMORE PLAZA HOLIDAY INN505 North Fifth Street
(605) 348-4000Free shuttle service available in town and from the airport.
TRAVEL LODGE2505 Mount Rushmore Road
(605) 343-5383 Or (800) 528-1234Located 1 mile from the Eye Institute. Free transportation to and from the
Eye Institute and pharmacies
Interstate-90
Omaha St.
Main St.
St. Joseph St.
St. Patrick St. Cam
bell
St.
5th
St.
I-190
Hain
es S
t.
LaC
rosse S
t.
Exit 59Exit 58
Exit 57
W. B
lvd.
3rd
St.
Mt
Ru
sh
mo
re R
d.
(8th
St.
)
Cathedral Dr.Fairmont Blvd.
BLACK HILLSREGIONAL
EYE INSTITUTE
RAPID CITYREGIONALHOSPITAL �
1679
Phone Number605-341-2000
Toll Free Number1-800-658-3500
Websitewww.blackhillseyes.com
All Phones AreAnswered
24 Hours A Day
Drop off and pick up areaavailable near front entrance.
2800 Third StreetRapid City, SD 57701
Just East of Rapid City Regional Hospital
Any patient requiring assistance transferring will need to be accompanied by someone who can aid in that transfer.
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