PATIENT BILL of RIGHTS for PROTECTED HEALTH INFORMATION (PHI)
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
III. A. Uses and Disclosur
Here are some examples of how we might have to use or disclose your health care information:
Your chiropractor or a staff member may have to disclose your health information including all of your clinical records to another health care provider or a hospital
if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition,
Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier,
an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your service
Your chiropractor and members of the staff may need to use our health information, examination and treatment records and your billing records for quality control
purposes or for other administrative purposes to efficiently run our practice.
Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide
appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If you are not home to receive
an appointment reminder, a message will be left on your answering machine. If you prefer, a text will be sent to your phone as an alternative.
You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health
related information at any time.
B. Our Privacy Pledge
We have an always will respect your privacy. Other than the uses and disclosures we described above, we will not sell or provide any of your health information
to any outside marketing organization.
C.Permitted uses and disclosures without your consent or authorization
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following
circumstance
We are permitted to use or disclose our health information if we are providing health care services to you based on the orders of another health care provider.
We are permitted to use or disclose your health information if we provide health care services to you as an inmate.
We are permitted to use or disclose your health information if we provide health care services to you in an emergency.
We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.
We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
Other than the circumstances described in the preceding five examples and under the Uses and Disclosures section above, any other use or disclosure of your health information will only be made with your written authorization.
D.Your right to revoke your authorization
You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:
If we have already released your health information before we receive your request to revoke your authorization.
If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they
decide to contest any of your claims.
If you wish to revoke your authorization please write to us at: Cedar Chiropractic & Sports P.C.
77 West Main St. Suite 203B
Hopkinton, MA 01748
E. Your right to limit uses or disclosures
If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health
information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not
required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may
drop your request or you are free to seek care from another health care provider.
F. Your right to receive confidential communication regarding your health information
We normally provide information about your health to you in person at the time you receive chiropractic services from us. We may also mail you information regarding our health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home or, if you would like the information in a different form. To help us respond to your needs, please make any request in writing.
G. Your right to inspect and copy your health information
You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing.
H. Your right to amend your health information
You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains
in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.
- required for your treatment, to obtain payment for your services, or to run our practice.
- to individuals involved with your care.
□ for national security or intelligence purpose.
- made to correctional officers or law enforcement officers.
- that were made prior to the effective date of the HIPAA privacy law, April 1, 2003.
We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you
make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.
J. Our duties We are required by law to maintain the privacy of your health information.
We are also required to provide you with this notice of our legal duties and our privacy
practices with respect to your health information.
We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the
terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will
pally for all of your health information in our files.
K. Re-disclosure
Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer by protected by the
federal privacy roles.
L. Your right to complain
You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be addressed to: Dept. of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Tel: (877) 696-6775
Cedar Chiropractic & Sports PC Financial Policy
We strive to provide the highest quality health care, all the while maintaining afford ability for you, the patient. We understand that
even with insurance, most patients will experience at least some out of pocket expense.
Participating Insurance
Our office will accept your insurance on assignment and do participate as preferred providers for many insurance plans. However, it
must be fully understood that your insurance policy is a contract between you and your insurance company. Our office will not enter
into a dispute with your insurance company over policy limitations or insurance policy issue. This is your responsibility and
obligation.All charges incurred are your responsibility. If you have a question or concern with your reimbursement, you will need to
contact your employer or insurance company. Our office will file your claims for you and assist you in every way possible to
ensure benefit recovery.We cannot be certain if your insurance covers chiropractic care, although most policies do provide
coverage. The amount they pay varies from one policy to another. We will call to verify benefits on your insurance; however, the
benefits quoted to us by your insurance company are not a guarantee of payment.It is our policy and agreed that any services
rendered are charged to you directly and you are responsible for payment of any non-covered services, deductibles or co-pays.
Non-Participating Insurances
We will gladly bill your Insurance for you, and will call to determine your chiropractic benefits. Payment is due at the time of service for all deductibles, co-pays, and non-covered therapies unless arrangements are with the office staff.
Patients without Insurance
We request that 100% of the examination and treatment be paid at the time of the visit, unless other arrangements have been made.
To qualify for our Time of Service Reduction in fees you must pay on the day the service was performed.
We are happy to accept cash, check, Master Card, Visa, Discover or American Express.No insurance will be billed.
Medicare
Our office accepts assignment from Medicare. Reimbursement is sent directly to our office in payment for chiropractic services that
Medicare will cover. Medicare will ONLY cover manipulation of the spine. Medicare pays 80%of the allowable fee once the
deductible has been met. You are required to pay the deductible and the remaining fees for services Medicare does not
reimburse.These non-covered services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or
nutritional supplements.Medicare patients are fully responsible for charges of non-covered services.Secondary insurance may or
may not pay for these non-covered services. Our office completes and files the forms for Medicare at no charge.
Secondary Insurance
Please inform us of any secondary insurance you may have. We will file and collect from your secondary insurance for services
covered by the secondary payer.
Flex Plans/Medical Savings Accounts
Please inform us if you have a medical savings account, or a 'flex spending plan'.We will be happy to provide you with a statement
of your charges for reimbursement.
Health Saving Accounts(HSA)/High Deductible Health Plan
Please inform us if you have an H.S.A. As Chiropractic is a qualified expense and this can be paid through your H.S.A. and billed to your
high deductible health plan.Please read the following office policy regarding assignments:
- At the beginning of your treatment in our office we will verify your policy benefit. However, phone or fax verification of coverage is never a guarantee of payment.
- Returned checks and balances over 90 days may be subject to additional collection fees and interest charges of 4% per month. Charges may also be made for missed appointments and those canceled without 24 hours notice.
- Your insurance will be filed as a courtesy to you. We file insurance claims on a weekly basis.
- You will be responsible for your full deductible and co-payment or co-insurance. Payment is due when services are rendered. If your insurance company does not pay something that was anticipated, you will be responsible for the amount as soon as we/you are of aware of the denial.
- If you pay the full amount for services rendered each visit, you may qualifying for our Time of Service (TOS) discount. You may then submit the bill to your insurance company for reimbursement.
- If your insurance company has not paid a claim within sixty (60) days of submission, you agree to take an active part in
the resolution of your claim. If your insurance company has not paid within ninety (90) days of submission, you are
responsible for payment of any outstanding balance.
- Our fees are considered usual and customary by most insurance companies, and therefore are covered up to the maximum
allowance determined by each insurance company. This statement does not apply to companies who reimburse based on
an arbitrary schedule of fees bearing no relationship to the current
Standard of care in this area.
Personal Injury (PI)or Automobile Accidents
Please present your auto insurance card, your health insurance card, and inform usif you have retained an attorney. If you need an attorney we will refer you to an attorney.
There are four options available to the PI patient:
- Pay cash for your care and we will submit reports whenever necessary.
- We will bill and accept assignment from the portion of your auto insurance.
- We will accept a Letter of Protection or Doctor’s Lien from an attorney.
- Account balances 90 days past the release date of treatment will incur a 4%monthly charge.
- We will bill your standard health insurance plan if your auto insurance policy medical coverage is exhausted and you will be
responsiblefor all co-pays and deductibles as they are incurred.
Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to 6(six)months after your
care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately
I have read and understand this financial policy. I realize that I am responsible for all charges incurred by meat Cedar Chiropractic & Sports
PC.
WE ask that you sign this form as acknowledgement of our financial policy agreement:Cedar Chiropractic & Sports PC
Financial Policy, were explained to you, that you understand it, and you accept full responsibility.