PRACTICE POLICY NOTIFICATION FOR PATIENTS
This notification covers a number of important aspects of my practice and your treatment. Please read it carefully and acknowledge receipt by signing at the bottom.
APPOINTMENTS
Please record your scheduled appointments in a calendar and keep track of appointments. You will not receive a reminder call for upcoming appointments. Response to telephone requests to be reminded of previously scheduled appointment dates cannot be guaranteed.
Payment in full is required at each appointment. Please arrange beforehand to pay by check made out to Karen Leo, M.D. or credit card. Dr. Leo is an out-of-network physician for all insurance companies. You will be provided with a Statement of Service that you can use to submit an insurance claim yourself if you wish to do so.
MEDICARE: Dr. Leo has opted out of Medicare. All Medicare beneficiaries are required to sign a private contract agreement with Dr. Leo stating that you will not submit claims for Dr. Leo’s services to Medicare.
Patients are financially responsible for the full session fee for scheduled sessions that are cancelled by the patient less than THREE FULL BUSINESS DAYS ahead of the appointment time. This policy also applies to missed appointments. Cancellations must be made by telephone, not email.
PRESCRIPTIONS
If medications are required, prescriptions will be written during the session. Please come to each session with a complete updated list of all prescription medications you take, over the counter medications and supplements, including doses. Without full knowledge of what you are currently taking, Dr. Leo may not be able to make medication or supplement decisions. Alternatively, you can bring all bottles with you for Dr. Leo to check. It is the patient’s responsibility to notify Dr. Leo of prescriptions that are running low and require refilling during the session time. Medication changes will be made at that time, if needed. If there is a need to adjust or change medication between sessions, that is a clinical matter that will be taken care of by Dr. Leo in consultation with the patient.
If a routine refill is needed outside of a session time, call your pharmacy and request the refill at least five days in advance. Notify the pharmacy that this office does NOT accept faxes, so they must call 925-254-2050. Next, call Dr. Leo’s voice mail and leave a message confirming that you want the prescription refilled with drug name, dose and instructions for taking it. If appropriate to do so, a one- month supply will be authorized. Because pharmacies often call for refills automatically, Dr. Leo will only respond to pharmacy calls when the patient has also left a message with Dr. Leo authorizing Dr. Leo to arrange for the refill. Calls from pharmacies requiring Dr. Leo to authorize routine refills outside of session time will result in a $50 charge to the patient for this additional service. This policy includes calls from mail order pharmacies. If a patient calls the pharmacy for a prescription refill using a prescription number where the most recent bottle indicates that there are no refills remaining, the pharmacy will automatically contact Dr. Leo for refill permission. Be sure to turn new prescription forms in to the pharmacy and ask them to check your file for that prescription when the old bottle has no remaining refills. Dr. Leo will not authorize a refill if you do not have a future appointment scheduled.
Insurance companies may require prior authorization to pay for some medications, and may change what medications they will cover during your contract year. Dr. Leo will discuss and handle prior authorization issues during scheduled sessions. If that is not possible, the standard session rate, pro-rated to time spent, will be charged. Unfortunately, even with best efforts and time spent, prior authorizations requests are frequently denied by insurance companies. Dr. Leo’s charge for time spent still applies.
CORRESPONDENCE
Letters requested for any purpose, including summarizing the medical record for life and medical insurance applications, medical leave or any other purpose will be charged at the standard session rate, pro-rated to time spent for appropriate record review, summarizing and letter composition.
You will be notified in advance of any request received by Dr. Leo from an outside agency, even if you have signed a release with the relevant agency. Simple forms presented at the beginning of a session can often be completed during that session.
TELEPHONE CALLS
Telephone calls between sessions lasting more than five minutes will be charged at the standard session rate, prorated to time spent.
I confirm I have read, understand and agree to the above policies for the practice of Karen J. Leo, M.D. These policies will remain in effect until they are replaced by a signed, updated Practice Policy Notification.
--------------------------------------------------------------------------------------------------------------
Signature/Date
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU WILL BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!
The office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
During the course of your treatment, the physician determines she will need to consult with another specialist in the area. She will share the information with such specialist and obtain his/her input.
Example of Use of Your Health Information for Payment Purposes:
Your health insurance company requests information from me regarding psychiatric care given. I will provide information to them about you and the care given.
Your Health Information Rights
The health and billing records I maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:
- Request a restriction on certain uses and disclosures of your health information by delivering the request to my office. I am not required to grant the request, but I comply with any request granted;
- Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at my office;
- Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to my office;
- Appeal a denial of access to your protected health information, except in certain circumstances;
- Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to my office. I may deny your request if you ask me to amend information that:
- Was not created by me, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the information that you would be permitted to inspect and copy; or
- Is accurate and complete.
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;
- Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to my office;
- Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to my office. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person's involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.
- Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to my office, except to the extent information or action has already been taken.
If you want to exercise any of the above rights, please contact Dr. Leo, in person or in writing, during regular, business hours. She will inform you of the steps that need to be taken to exercise your rights.
My Responsibilities
The office is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice as to my duties and privacy practices as to the information I collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if I cannot accommodate a requested restriction or request; and,
- Accommodate your reasonable requests regarding methods to communicate health information with you.
I reserve the right to amend, change, or eliminate provisions in my privacy practices and access practices and to enact new provisions regarding the protected health information I maintain. If my information practices change, I will amend the Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of the "Notice".
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Dr. Leo.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at my office by delivering the written complaint to Dr. Leo. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services.
- I cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.
- I cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Other Disclosures and Uses
Communication with Family
- Using my best judgment, I may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.
Notification
- Unless you object, I may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Food and Drug Administration (FDA)
- I may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Workers Compensation
- If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
Public Health
- As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.
Abuse & Neglect
- I may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
Law Enforcement
- I may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.
Health Oversight
- Federal law allows me to release your protected health information to appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
- I may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
Serious Threat
- To avert a serious threat to health or safety, I may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions
- I may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Coroners, Medical Examiners, and Funeral Directors
- I may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. I may also release health information about patients of Covered Entities to funeral directors as necessary for them to carry out their duties.
Other Uses
- Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights."
Acknowledgment of Receipt of Privacy Practices
I acknowledge that I have received a copy of Dr. Leo’s Notice of Privacy Practices with the effective date of: