YOU WILL BE ASKED TO SIGN THIS DOCUMENT ELECTRONICALLY
This document is posted in our waiting room. Any patient may request a print of this document upon signing.
Due to the continuing changes in the health care industry, we would like to provide you with our practice policies and how they relate to you.
CO-PAYS: If you have an insurance that requires a patient co-pay, it must be paid at the time of the service. The Doctor may refuse your visit if your co-pay is not remitted. This office may impose a fee of $5.00 to invoice your co-pay to you.
If you have no insurance coverage: Payment must be made at the time of the service unless an acceptable payment plan has been agreed upon staff prior to the services rendered.
Our office participates with MOST insurance companies, it is your responsibility to contact your insurance carrier and allocate your Primary Care provider and ensure participation in your plan prior to your scheduled appointment. Failure to do so may result in cancellation or your requirement to sign our Non-participating/Un-confirmed Insurance form (s).
If we do not participate with your insurance carrier: We will file the claim if you provide us with the following information: Name and mailing address of your insurance carrier, policy number, group number, policy holders’ full name, policy holders’ date of birth and social security number. We file these claims as a courtesy to our patients so that your insurance carrier reimburses you in a timely manner. We will bill your insurance company only once per service, the responsibility of the service remains the patient’s responsibility. The patient is responsible to pay the bill within 30 day of the service date.
Liability: Carriers usually remit payment to the patient or the patient’s attorney if one has been retained. OUR POLICY DOES NOT ALLOW US TO HOLD ACCOUNTS WHICH ARE PENDING RESOLUTION OF ANY LIABILITY OR LITIGATION ISSUES. WE DO NOT, UNDER ANY CIRCUMSTANCE, BILL ATTORNEYS. If you provide a letter from the liability carrier indicating they accept full responsibility and will remit payment, we will submit on your behalf. Otherwise, you may either have charges submitted to your private carrier or pay for services and obtain reimbursement upon resolution/settlement.
Fees and collections: I agree to pay for items not covered by a third party; these fees include but are not limited to a $ 50.00 missed appointment fee, Forms fees of up to $ 15 per sheet, non-sufficient check fee of $ 50.00, billing fees plus 30% if a collection agency is associated with past due balances.
Invoice Fees: after 2 invoices on a patient balance, a fee of $ 5.00 per invoice may be added and these fees will be cumulative until the balance is paid or sent to collections.
LAB WORK/HOSPITAL coverage: Please be advised that many insurance companies require you to go to a certain lab and/or hospital. YOU will be responsible to pay your bill if you go to a lab and/or hospital that is not covered by your insurance carrier. Please check with your insurance company to see where you should go for these services.
LAB WORK/HOSPITAL PROCEDURES: If you are hospitalized or treated at an ER/URGENT Care or other clinic, PLEASE reach out to our office and let us know where you are being treated so we may obtain your records.
No-Fault/Workers Compensation: You are responsible for providing our office with the necessary information needed to properly submit charges. If you fail to do so, the fees mandated by NY State will be changed to reflect our private fees and you will be responsible for payment. Some No-fault carriers have deductibles on medical charges, for which the patient (not the insured) is responsible. If you have private insurance, we will submit on your behalf and bill you for any unpaid balances.
Medicare Lifetime Signature
I request that payment of authorized Medicare Benefits be made on my behalf to provider for any services rendered to me by the physician. I authorize any holder of medical information about me to be release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.
WE ACCEPT CASH, CHECKS, VISA, Master Card WE OFFER AN EXTENDED PAYMENT (BUDGET) PLAN.
We encourage our patients to discuss their financial circumstances with our billing service, they will be happy to assist you with questions and payment plans. Their information is located at our front desk.
Notice of Privacy Policies
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to you past, present, or future physical or mental health or condition and related heal care service.
- Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
HEALTH CARE OPERATIONS: we may use or disclose, as needed, your protected health information in order to support the business activities of your physicians practice. These activities include, but are not limited to quality assessment activities, employee review activities, training of medical students, licensing, and conduction or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization: as Required by law, Public Health Issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers Compensation: Inmates: Required Uses and Disclosures: Under the law we must make disclosures to you and when required by the Secretary of the Department of Health and Human service to investigate or determine our compliance with the requirements of Section 164.500
OTHER PERMITTED and Required uses and disclosures will be made only with your consent; You may revoke this authorization at any time, in writing, except to the extent that your physician has taken an action in reliance on the use or disclose indicated in the authorization.
- Your Rights
You have the right to: inspect and copy of protected health information; however, you may not inspect or copy the following records: psychotherapy notes; information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to the law that prohibits access to protected health information. The practice may charge you a fee to copy such information.
You have the right to: request a restriction of your protected health information; you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request, in written form, that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restrictions.
Your Physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, it will not be restricted. You then have the right to use another health care professional.
You have the right to: request to receive confidential communications for us by alternative means or at an alternative location.
You have the right to: obtain a paper copy of these notices from us, upon request, even if you have agreed to accept this notice electronically.
You may have the right: to have your physician amend your protected health care information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and provide you with a copy of such statement.
You have the right to: receive an accounting of certain disclosure we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail or office posting. You then have the right to object or withdraw as provided in this notice.
Complaints: You may complain to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact: Kaitlynn Lester at extension 11.
We will not retaliate against you for filing a complaint.
By signing our electronic version of this Financial Policy and Notice of our Privacy Practices you have acknowledged you have received it.
Our Practice Policy and Mission Statement
Our Mission Statement
Our Providers seek to improve the health of our patients by providing compassionate, high-quality health care through preventative medicine, ongoing care, support and continued accreditation for Patient Centered Medical Home.
We will make a connection with you, learn your conditions and work to Prevent new disease. We will learn your family history, risk factors and other important conditions that can influence your health. We will make decisions together and we will coordinate your care across multiple settings and specialty care. You will receive a care plan and you will be given a summary of each visit for that day. We will go over your medications and give you clear instructions of you to achieve your treatment goals.
All patients must play an active role in your health care. Learn about your condition and what you need to do to stay healthy. Participate in your Care Plan and take your medications as directed. HAVE ALL PREVENTATIVE tests and immunizations done and keep your Care Team informed of any changes or hospitalizations. This will ensure that your care is properly coordinated so that we can help you achieve your health care goals.
Failure to comply with our Annual well Visit, Annual Labs, or the preventative measures spelled out by your carrier, the CDC/Medicare and/or your Physician may result in termination from the practice.
It is the patient’s responsibility to keep informed of the policies or the changes to these policies
We welcome you to our practice and look forward to providing your medical care. Please do not hesitate to ask our staff if you have any questions regarding the above information.