Policy Form

Patient Information Acknowledgement

In the event that it becomes necessary for Optic Gallery to release and/or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Justin Ng, Dr. Tracy Tran, or any of their associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Justin Ng, Dr. Tracy Tran, or any of their associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies.
I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY.

In the event that it becomes necessary for Optic Gallery to release and/or request your records from another healthcare professional your written permission is required. I authorize Optic Gallery, Dr. Justin Ng, Dr. Tracy Tran, or any of their associates to release and/or request these records.

It is policy of this office to require:

1. Payment in full before the order can be placed.
2. All balances that are left on the account must be paid in full upon patient/guardian pick up.
3. All orders are final when placed.

Patient Privacy Notice Summary:
Earning and maintaining your trust and safeguarding your privacy is the cornerstone of our patient relationship with you. The protection of your privacy is a key part of maintaining your trust. This has been a fundamental operating principle of Optic Gallery Pahrump since our founding and remains so today. This patient privacy notice summary lets you know we maintain strict internal policies regarding confidentiality of patient information (PPI) we maintain physical, electronic and procedural safeguards that comply with federal guidelines to safeguard patient information. Our employees are bound by our policies to access patient information only for legitimate clinical and/or business purposes and to keep such information confidential at all times. We pledge to do all we can to protect your privacy. If you have any questions about our privacy policy, or about how our information is maintained, safeguarded or used please contact our privacy officer, Trudie Lee at (702) 938-2020. Signing this section signifies that you have read and received a copy of our Notice of Privacy Practices.

Medical Services Contract:
I hereby authorize and consent to medical treatment by Optic Gallery Pahrump for me (or my child). I authorize Optic Gallery Pahrump to release my (or my Dependant's) medical records to our family doctor and to any insurance company, adjuster, attorney, authorized agent working on behalf of Optic Gallery Pahrump or other authorized parties. I understand that I am responsible for payment of all vision and medical treatment rendered to me by Optic Gallery and I agree to pay all co-payments, deductibles, and non-covered services at the time of visit. I understand that, as a courtesy to me, Optic Gallery Pahrump will file a claim with my insurance carrier and I authorize payment directly to Optic Gallery Pahrump for the benefits otherwise payable to me under the terms of my insurance coverage. I understand that I am responsible for maintaining current coverage information to meet filing deadlines and for the payment of any remaining balance after payment from my insurance carrier.

Consent for Dilation of the Eyes:
In order to perform a thorough and complete ocular exam, it will be necessary for us to dilate your pupils. Dilation allows the doctors at Optic Gallery Pahrump to obtain a better view of the back of the eye. Many medications, vitamins, and foods can influence the health of your eyes and vision. Diseases such as High Blood Pressure, Diabetes, Arthritis, Auto-immune disorders and many other conditions can affect our ocular health and vision. Dilation specifically allows us to examine the Optic Nerve, Blood Vessels, Macula and extreme edges of the retina in detail.

Side effects of dilation include blurry vision at distance and near and light sensitivity for approximately 4-6 hours. Our Doctors strongly recommend caution when driving or operating equipment or machinery after dilation. Signing below signifies you have been informed of the risks and benefits of dilation; I understand having my eyes dilated will require a minimum 30 minutes or more during the examination. Please select one of the options below:

Electronic Communication:​​​​​​​
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I give permission to be in contact via text message, email, and/or Patient Portal with our Electronic Medical Records System.

Late Policy

If you are 15 minutes late to your scheduled appointment time, your appointment will be re-scheduled and you have the option of being a walk-in.

Cancellation of Appointment(s)/No-Show Policy

Patients wanting to cancel an appointment are asked to call the office by a minimum of 4 hours prior to the appointment time. The charge for not cancelling within a 4 hour notice is $25.00, which will be charged to the patient/guarantor and is NOT payable by any insurance company. Patients who do not show up for their appointment without a call to cancel will be considered a NO SHOW. Patient who No-Show 3 or more times in a 12-month period may be dismissed from the practice and thus they will be denied any future appointments. All no-show fees MUST be paid prior to the next appointment in order to be seen.