HIPAA, the Health Insurance Portability and Accountability Act of 1996 has recently been formalized and will help govern the relationship between patients and their providers of Health Care to provide all entitled Medical Services in the most efficient way. This notice described how health information about you may be used and disclosed and how you can get access to this information.
PLEASE READ AND REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
We may use and disclose health information about you for treatment, payment and health care providers. Treatment: We may disclose your health information to physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our health care operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioners and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Appointment Reminders: Treatment alternatives and Health Related Benefits and Services: We may use and disclose your health information to contact and remind you of an appointment with us. We also may use and disclose health information to inform you of treatment alternatives or health-related benefits and services that may be of interest of you.
Individual Involved in Your Care or Payment for Your Care: When appropriate, we may share your health information with a person who is involved in your medical care or payment for your care. We also may notify your family about your location or general condition to disclose such information to an entity assisting in a disaster relief effort.
SPECIAL SITUATIONS
As Required by Law: We will disclose your health information when required to do so by international, federal, state of local law.
Military and Veterans: If you are a member of the armed forces, we may release your health information as required by military command authorities.
Workers' Compensation: We may release your health information for workers' compensation or similar programs.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to subpoena, discovery request, or Other lawful process by someone else involved in the dispute but only if efforts have been made to tell you about this request or to obtain an order protecting the information requested.
Law Enforcement: We may release your health information If asked by a law enforcement official if the information is 1. in response to a court order, subpoena, warrant, summons or similar process 2. limited information to identify or locate a suspect, fugitive, material witness, or missing person 3. about the victim of a crime even if, under certain circumstances, we are unable to obtain the person's agreement 4. about a death we believe may be the result of a criminal conduct 5. about criminal conduct on our premises and 6. in an emergency to report a crime, the location of the crime or victims, or the identity description or location of the person who committed the crime.
Inmates or individuals in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your health information to the correctional institution or law enforcement official. This release would be, if necessary 1. for the institution to provide you with health care 2. to protect your health and safety or the health and safety of others or 3. the safety and security of the correctional institution.
Access: You have a right to inspect and copy your health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records other than psychotherapy notes. (To inspect and copy your health information, you must make a request in writing).
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, or for which you provided written authorization.
Restriction: You have the right to receive a list of instances in which we or our business associates disclosed your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by your agreement (except in an emergency).
Confidential Communication: You have the right to request that we communicate with you about medical matters by alternative means or to alternative locations. You must make a request in writing. Your request must specify the alternative means or location. We will accommodate reasonable requests.
Amendment: If you feel that your health information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. You must make a request in writing.
We are required by law to give you this notice and help you understand its intent. You must signify your understanding and agreement by signing in the appropriate spaces. You may opt for this agreement at any time by presenting this office with written notice of your wishes.
I authorize the doctor to release medical information including diagnosis, x-ray, test results, reports, and records pertaining to any treatment of examination rendered to me. I understand that this medical information can be used for any of the following Diagnostics, Insurance, and other Legal purposes at times when the doctor deems it necessary in order to ensure the best medical care and accuracy in treatments on my behalf. I further understand that any person(s) that receive these medical records will not release any information obtained by this authorization to any other person or organization that is necessary to comply. If this policy is changed, we will notify you in advance.
If you have any questions about this notice, please contact our office directly. We appreciate the trust that Patients place in us and we recognize the importance of protecting the confidentiality of non-Public personnel information that we have in our possession.
Thank you for choosing our practice as your health care provider. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which must be read and signed before any treatment.
Patients must complete our patient information form and present necessary insurance cards, forms, and/or referrals before seeing the doctor. Any existing patient with changes in information (address, phone numbers, and insurance information) must complete a new information form or advise the receptionist of such changes. It is your responsibility to verify whether the address and phone number that was given to us is correct. If you fail to do so you will be responsible for the balance due on your account.
I understand and agree that co-payments are due at the time of the visit regardless of my insurance status. I am ultimately responsible for the balance of my account for any professional services rendered. Exact change for co-pay, deductible, and co-insurance is needed at the time services are rendered.
Payments are expected in full once statements are sent out to you. Please render payment for outstanding charges promptly. Delay in payments on accounts with 60 days past due may be transferred to the collection agency.
Insurance provides reimbursement on allowed medical charges. We will submit to most insurance carriers. Make sure you have provided us with all pertinent information. It is your responsibility to check with your insurance whether we are IN or OUT of network. Please understand that as a third party. we cannot become involved in prolonged insurance negotiations. Accounts with 60 days past due from your insurance will be automatically be billed to you. It is your responsibility to maintain your records.
It's your responsibility to verify your coverage and benefits with your insurance carrier. Please note that if at the time of service you have not satisfied your Deductible and Out of Pocket, we will collect the applicable amount up front. However, the deductible and co-insurance amounts collected from you at the time of service do not include reimbursement for any required additional services provided to you during procedures. We will send claims to your insurance and once these claims are finalized a statement will be mailed as well as a copy of explanation of benefits we receive for your insurance carrier.
Your insurance may deny payment for services considered by its reviewers not to be medically necessary, not covered, or pending. If this occurs payment is expected in full from you. Please verify with your insurance or group whether the scheduled service is covered/authorized.
I authorize the release of any medical information necessary for process of any claim. I permit a copy of the authorization to be used in place of the original. Either my insurance company or I may revoke an authorization at any time in writing.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Or responsible party (if other that patient)
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: