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Forms & Policies

At NECO Center for Eye Care, privacy about your health information is our priority. Our policies have been established to assist and protect patients and staff and to ensure we are HIPPA compliant.

Patient Forms 

The following forms and policies are provided to assist and protect patients and staff. They are available to view online or to download. Please note that forms that require a signature must be downloaded and signed before sending via email or presented at our clinics. 

Patient Policies


HIPPA Privacy Rule

The HIPAA Privacy Rule (Health Insurance Portability and Accountability Act of 1996) created national standards to help protect a patient's personal health information (PHI) and medical records and how they are transmitted electronically.  NECO Center for Eye Care adheres to a strict set of practices to protect your health information and comply with HIPAA Privacy Regulations. You may download a copy of our privacy practice here. You may also view our privacy statement.


Patient Rights & Responsibilities

The NECO Center for Eye Care is committed to providing quality health care. It is our pledge to provide this care with respect and dignity. In keeping with this pledge and commitment, we present the following Patient Rights and Responsibilities:

You have the right to:

  • A personal clinician who will see you on an on-going, regular basis.
  • Competent, considerate and respectful health care, regardless of race, creed, age, sex or sexual orientation.
  • A second medical opinion from the clinician of your choice, at your expense.
  • A complete, easily understandable explanation of your condition, treatment and chances for recovery.
  • The personal review of your own medical records by appointment and in accordance with applicable State and Federal guidelines.
  • Confidential management of communication and records pertaining to your medical care.
  • Information about the medical consequences of exercising your right to refuse treatment.
  • The information necessary to make an informed decision about any treatment or procedure, except as limited in an emergency situation.
  • Be free from mental, physical and sexual abuse.
  • Humane treatment in the least restrictive manner appropriate for treatment needs.
  • An individualized treatment plan.
  • Have your pain evaluated and managed.
  • Refuse to participate as a subject in research.
  • An explanation of your medical bill regardless of your insurance and the opportunity to personally examine your bill.
  • The expectation that we will take reasonable steps to overcome cultural or other communication barriers that may exist between you and the staff.
  • The opportunity to file a complaint should a dispute arise regarding care, treatment or service or to select a different clinician.

You are responsible for:

  • Knowing your health care clinician’s name and title.
  • Giving your clinician correct and complete health history information, e.g. allergies, past and present illnesses, medications and hospitalizations.
  • Providing staff with correct and complete name, address, telephone and emergency contact information each time you see your clinician so we can reach you in the event of a schedule change or to give medical instructions.
  • Providing staff with current and complete insurance information, including any secondary insurance, each time you see your clinician.
  • Signing a “Release of Information” form when asked so your clinician can get medical records from other clinicians involved in your care.
  • Telling your clinician about all prescription medication(s), alternative, i.e. herbal or other, therapies, or over-the-counter medications you take. If possible, bring the bottles to your appointment.
  • Telling your clinician about any changes in your condition or reactions to medications or treatment.
  • Asking your clinician questions when you do not understand your illness, treatment plan or medication instructions.
  • Following your clinician’s advice.  If you refuse treatment or refuse to follow instructions given by your health care clinician, you are responsible for any medical consequences.
  • Keeping your appointments.  If you must cancel your appointment, please call the health center at least 24 hours in advance.
  • Paying copayments at the time of the visit or other bills upon receipt.
  • Following the office’s rules about patient conduct; for example, there is no smoking in our office.
  • Respecting the rights and property of our staff and other persons in the office.
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