NOTICE OF HEALTH INFORMATION PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

Understanding Your Health Record/InformationEach time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment.

This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal documentation describing the care you received
• Means by which you or a third party payer can verify that services billed were actually provided
• A source of information for public health officials charged with improving the health of the nation
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

• Ensure its accuracy
• Better understand who, what, when, where, and why others may access your Health information
• Make more informed decisions when authorizing disclose to others

Your health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that complied it, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information as Provided by 45 CFR 164.522
• Obtain a paper copy of the notice of information practices upon request
• Inspect and obtain a paper copy of your health record as provided for in 45 CFR 164.524
• Amend your health record as provided in 45 CFR 164.528
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
• Request communication of your health information by alternative means or at alternative locations
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken

Provider Responsibilities:

This office is required to:

• Maintain the privacy of your health information
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• Abide by the terms of this noticeNotify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
• We will not use or disclose your health information without our authorization, except as described in this notice

This office reserves the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post those changes at this office.

Examples of Disclosure for treatment, Payment and Health Operations We will use your health information for treatment.

For example: Information obtained by nurse, P.A.C., Nurse Practitioner. Or other member of your healthcare team will be in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations. Your physician may request ancillary or specialty care services.Those providers will record their care services. Those providers will record their care in their records and copy your physician on their observations. In that way, the physician will know how you are responding the treatment.

This office will use your health information for payment/encounter data.

For example: a bill may be sent to you or a third party payer or HMO. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis. Procedures, and supplies used.

This office will use your health information for regular health operations.

For example: Members of the Utilizations Review Committee or Quality Improvement Council may use information in health record to assess the care and outcomes in your case. This information will then be uses in an effort to continually improve the quality and effectiveness of the healthcare services we provide.

Research: This office may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research

Funeral Directors: This office may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Patient Education: This office may give you name, phone number, and diagnosis to the Health Education Department who will contact you to provide appointment reminder or information bout treatment alternatives or other health related benefits and services that may be of interest to you.

Workers Compensation/TPL: This office may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or third party or other similar programs established by law.

Public Health: As required by law, this office may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

IEITS- Inland Empire Immunization Tracking System: This office may report immunization information to be included in the statewide database accessed only by healthcare providers, database managers, and public officials.

Correctional Institution: Should you be an inmate of a correctional institution, this office may disclose to the institute or agents thereof health information necessary for you health and the health safety of other individual.

Law Enforcement: This office may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Federal and state law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney to evaluate professional or clinical standards.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Practice Policies

Welcome to our office!!

Enclosed you will find our new patient paperwork. Please complete and sign all of these forms prior to your appointment. If you have any questions regarding any of the information requested, please call our office prior to your visit date. We do require that all the enclosed forms, including the arbitration agreement be completed and signed. We realize this is a lot of paperwork, therefore we request that you mail the forms back to our office or that you arrive 30 minutes early on the day of your appointment. If previous medical records are necessary for your appointment, please forward the records in advance to facilitate your visit.

Work Hours:

The office is open from Monday to Friday, 9 AM to 5 PM, except on Wednesdays from 9 AM to12 Noon; the office is closed for daily lunch from 12-2 PM, and on weekends and holidays.

Scheduling routine well check visits and/or routine physical exam visits:

You understand that Dr. Quintanilla will explain which regular health screenings are appropriate for the patient's age, gender and/or personal/family history; you understand that there are recommended health screening visits and tests that can help detect life-threatening diseases and conditions, if you visit the doctor only for immediate problems and forget to arrange for regular health screening visits, you put your child at risk of letting serious health problems going undetected, therefore you understand that you will schedule regular visits to complete physical exams and to allow regular health screenings to be performed.

Follow-up Appointments and Missed Appointments:

You understand that Dr. Quintanilla needs to know about the progress of a condition after leaving the office and returning to the doctor on time gives him the chance to check on the condition and the response to treatment. If you cancel or miss your appointment and do not re-schedule you run the risk of the physician not being able to detect and treat a serious health condition. Therefore, you will make every effort to re-schedule missed or cancelled appointments as soon as possible.

Lab and Test results policy:

Routinely Dr. Quintanilla will report abnormal lab and/or test results as soon as possible, however if you do not hear form the physician's office within the time specified, you understand that you will call the office requesting those results.

Prescription Policy:

Dr. Quintanilla prefers to examine a patient before issuing a prescription. Depending on special circumstances, at times phone prescriptions are called in to the pharmacy contingent on the patient scheduling a follow-up appointment within a minimum of 72 hr; under no circumstances a prescription will be provided in patients who have not been to the office within the past 3 months.

After-Hours coverage:

Dr. Quintanilla is on call after hours for emergencies ONLY; he is not on-call for office related issues, non-emergency questions, billing issues and/or for prescription refills. These issues can be resolved during normal business hours; please have pen and paper readily available when calling the on-call physician.

Dr. Quintanilla however is not on call 24/7; he shares after-hours coverage with a group of pediatricians at Eisenhower Hospital in Rancho Mirage and with another group at Desert Hospital in Palm Springs. These pediatricians will be covering for our practice patients when Dr.Quintanilla is not on call. Keep in mind that these physicians are on-call for emergencies ONLY; they provide essential medical advice only and routinely do not call in prescriptions.

If a patient requires after-hours medical service, the practice recommends VIP Urgent Care in Rancho Mirage, (760) 674-1923, where a pediatric patient can obtain excellent medical service:VIP however closes at 9 PM and after that time the ER at either Eisenhower or Desert Hospitals is available; Dr. Quintanilla will be notified by the ER if further care is necessary.

Payment Policy

If you have insurance that you would like us to bill, we need you to bring your insurance card or insurance information with you to your appointment; without this information we cannot bill your insurance and you will be asked to pay for services rendered on your appointment day.

If you have a deductible that has not been met, we will collect 50% of the charges for that day's visit and bill your insurance. Once our claim has been processed by your insurance company, we will bill you for the balance due. All outstanding balances and co-pays are due at time of service, if you are unable to make your payment, your appointment will be re-scheduled.

If you are scheduling an "annual well exam call your insurance company and verify that this type of service is covered prior to making your appointment; if well exams are not covered by your plan, you will be required to pay for services rendered on that day.

Although we are glad to bill your insurance, remember that it is your responsibility to ensure that our claims are paid, and if or when our claims are denied you become ultimately responsible for the balance due.

Cancellation Policy:

Unexpected events happen and we will be glad to reschedule any cancelled appointment for any reason at least 24 hours advance notice. Failure to cancel an appointment at least 24 hr in advance will result in a $25 "no show" fee applied to your account. Depending on the circumstances, repeated "no show" visits may result in the termination as a patient.

Chart Copies:

It must be clearly understood that Dr. Quintanilla is the legal custodian of your children's medical records; parents are not the owners of those medical records, however they are entitled to a copy of those records if requested; the practice does not charge for the actual photocopies of the records but there is a one-time clerical fee of $35 to cover all expenses, including chart retrieval from storage, fuel surcharge, certified or regular mail expenses, and others; in addition, charts are not retrieved immediately, please make sure to request your copies with appropriate anticipation because they are retrieved and copied on a once-weekly basis; for your information California State law allows the practice a maximum of 2 weeks before producing the records.

Safety measures in the office:

Our office is designed and built according to California building code and meets state safety standards; also, we have taken extra steps to keep the office safe for your child, however in order to prevent potential accidental injuries, parents need to keep close supervision of their children inside the office and therefore follow simple safety rules, such as never leaving your child alone. not sitting on exam stools, not playing with medical equipment, not running in the premises, and other common sense supervision.

Commitment Message.

Thank You for choosing Arturo Quintanilla MD PEDIATRICS for the well being of your precious children!!....We will do our best to provide quality and competent medical services.

By signing below you understand and accept these practice policies, you agree to become responsible for payments related to medical services, and you waive all responsibility from the office of Arturo Quintanilla, MD PEDIATRICS in the event of an accidental injury inside the office:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.