LETTER OF AGREEMENT FOR PARTICIPATION IN InfantSEE®
I am a member of the American Optometric Association (AOA), and agree voluntarily to participate in the AOA InfantSEE® program commencing on the date of submission of this agreement. I further agree to adhere to and abide by all the conditions and requirements of the InfantSEE® program as set forth in this Letter of Agreement, understanding and acknowledging that failure to do so shall result in my immediate and automatic termination from the InfantSEE® program with removal of my name from the Doctor Locator InfantSEE® provider list on the AOA and InfantSEE® websites.
Conditions and Requirements
1. The InfantSEE® program, as approved by the U.S. Department of Health and Human Services Office of Inspector General in 2004, involves a onetime no-charge comprehensive eye assessments to infants between the ages of 6 – 12 months. As an InfantSEE® provider, I agree to provide such comprehensive assessments. At no time will I charge any fee for these comprehensive eye assessments, whether to the patient’s family or any third party payer, including any Federal health care program. Also, at no time will I make the eye assessment offered through the InfantSEE® program contingent upon the provision of any other services, whether at the same time as the comprehensive examination or afterward.
a) If a parent or guardian makes an appointment with my office for an infant aged 6 – 12 months in relation to a specific condition noted at the time the appointment is made, then it is permissible to charge a fee for that visit. This is not an InfantSEE® assessment, because the purpose of the visit is to seek treatment for already existing or suspected condition. I will make it known to the person making the appointment that this does not fall under the InfantSEE® program restrictions. This should be made clear to the parent or guardian when the appointment is confirmed.
2. I am a licensed optometrist in my state of practice.
3. If, in my professional medical judgment, I determine to recommend that the infant patient receive additional examinations, treatments, or therapies, I will advise the infant’s parent or legal guardian verbally and in writing that he or she is free to choose any practitioner for those additional services. This written notification will be in a form that the parent or legal guardian can easily take with him or her.
4. I will share with the InfantSEE® program the outcomes of the eye assessments that I perform through the InfantSEE® program. Such information shall be shared in a manner that does not disclose Personal Health Information in violation of the patient privacy rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The InfantSEE® program, where practicable, may require that I fill out reporting forms to comply with this requirement, or use an electronic reporting system for this purpose and/or report through the AOA’s MORE clinical registry.
5. I agree to protect and use the trademarked InfantSEE® name and logo only as expressly permitted in this Letter of Agreement, as follows:
a) I am granted a limited, non-exclusive license to use the trademarked InfantSEE® name and logo only for purposes of generally advertising that I am participating in the InfantSEE® program. Advertisements may only contain the official description of the InfantSEE® program as described on the InfantSEE® website. No advertisement shall contain any other references or make any other statements concerning the InfantSEE® program, unless expressly approved in advance in writing by the staff administrators at the American Optometric Association. No advertisements containing a reference to the InfantSEE® program shall contain any other material that would violate state or federal laws or state professional conduct laws, regulations, or rules applicable to optometrists.
b) I will share questions from the press or other non-patient sources about specific details of the InfantSEE® program with the InfantSEE® staff administrators at the American Optometric Association. The American Optometric Association Communications Group may contact me to assist with press releases and public messaging about my practice and participation in InfantSEE® at which time I may choose to participate or not.
c) Whenever using the InfantSEE® name or logo, I will ensure that the appropriate trademark symbol is inserted/attached. This symbol consists of the small, uppercase (superscript) ® immediately to the upper right of the name of the program, as used throughout this Letter of Agreement.
d) I will use the InfantSEE® name and logo only as exactly provided to me by the InfantSEE® program, with no alterations of any kind unless expressly approved in advance in writing by the InfantSEE® program administrators.