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Privacy and Financial Policies Acknowledgment


Please indicate your acknowledgment of our Privacy Policy and Financial Policy by checkmarking the appropriate boxes and filling out the form below. Required fields are marked with asterisks (*).


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Clinic Location: *

ABQ-North Valley - 6601 4th Street
ABQ-Northeast Heights - 9204 Menaul Blvd.
ABQ-Westside - 1646 Alameda Blvd.
Los Alamos - 800 Trinity Drive


Privacy Policy & Acknowledgment

We are required by law to protect the privacy of your medical information and to provide you with written Notice describing:


We may use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment.

We may be required or permitted by certain laws, regulations, or circumstances to use and disclose your medical information for certain purposes without your authorization. Under other circumstances we may need your written authorization (that you may later revoke) in order to use or disclose your medical information.

As our patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed NOTICE OF PRIVACY PRACTICES which fully explains your rights and our obligations under the law. We may revise our NOTICE from time to time. The Effective Date at the top right hand side of this page indicates the date of the most current NOTICE in effect.

You have the right to receive a copy of our most current NOTICE in effect. If you have not yet received a copy of our current NOTICE, please ask at the front desk and we will provide you with a copy.

If you have any questions, concerns or complaints about the NOTICE or your medical information, please contact the HIPAA Officer at Cottonwood Vision Care at 505-792-3500.


Financial Policy & Acknowledgment

Please take a moment to review our policy on patient financial responsibility. Your signature below indicates acknowledgement of this policy.

For Patients with Vision/Medical Insurance Plans

Based on the information you provided, we have determined that we have a working relationship with your vision and/or your health insurance company. Therefore, we will bill your vision and/or health insurance carrier directly. You are responsible for payment of non-covered charges at the visit such as co-payments, deductibles, and overages - most of which have been established by your insurance companies.

As we have no control over your insurer's payment schedule or interpretation of their responsibility, and because our agreement is with you - not your vision or health insurance company - if we do not receive reimbursement from your insurance company in 45 days, we must seek payment from you.

As a Primary Health Care Provider we will bill your examination to your medical insurance carrier. Claims for glasses, contact lens fitting fees, and contact lens materials will be billed to your vision plan. If a claim for examination services is denied by your medical insurance carrier, the services may be covered by your vision plan. Please present your current major medical insurance card at the time of your visit.

For Patients without Vision/Medical Insurance Plans

You are responsible for examination charges at the time of the visit. Glasses and contact lens purchases require a 50% deposit before ordering, and the balance when delivered. All payment arrangements must be made in advance. Any account more than 60 days past due is charged a $5.00 monthly rebilling fee.


Electronic Signature

By entering the information below, I acknowledge that I have been advised of Cottonwood Vision Care and Atomic Eyecare's Privacy and Financial Policies, and my understanding and my agreement to the terms.

Name (Last, First, MI): *

Parent or Guardian: *

Patient's Date of Birth: *

Last 4 Digits of SSN: *


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1646 Alameda NW, Albuquerque, NM  |  800 Trinity Drive, Suite J-2, Los Alamos, NM