Out
of Network Agreement (If applicable)
As discussed,
your doctor is an out of network provider. A claim will be filed on your
behalf by this office to your insurance company. Payment will be sent
directly to you by the insurance company with an Explanation of Benefits
(EOB). You agree to endorse the payment to us and supply us with a copy of
the EOB. You may resolve a bill for any co-payment and deductible imposed by
your insurance company.
ASSURANCE OF PRIVACY FOR OUR PATIENTS
To Our Valued Patient:
The misuse of Personal
Health Information (PHI) has been identified as a national problem causing
patients inconvenience, aggravation, and money. We want you to know that
all of our employees, managers, and doctors continually undergo training so
that they may understand and comply with government rules and regulations
regarding the Health Insurance Portability and Accountability Act (HIPAA) with
particular emphasis on the “Privacy Rule”. We strive to achieve the very
highest standards of ethics and integrity when performing service to our
patients.
It is our policy to properly determine appropriate use of PHI
in accordance with the governmental rules, laws, and regulations. We want to
ensure that our practice never contributes in any way to the growing problem of
improper disclosure of PHI. As part of this plan, we have implemented a
Compliance Program that we believe will help us prevent any inappropriate use
of PHI.
We also know that we are not perfect! Because of this fact,
our policy is to listen to our employees and our patients without any thought
of penalization if they feel that an event in any way compromises our policy of
privacy and integrity. More so, we welcome your input regarding any service
problem so that we may remedy the situation promptly.
NOTICE
OF PRIVACY
The Department of Health
and Human Services has established a “Privacy Rule” to help ensure that
personal health care information is protected for privacy. The Privacy Rule
provide standards for health care providers to follow when disclosing health
information about the patient that is needed to carry out treatment, payment, or
health care operations.
As our patients, we want you to know that we respect the
privacy of your personal medical records and will do all we can to ensure and
protect that privacy. We strive to always take reasonable precautions to
protect your privacy. When it is appropriate and necessary, we provide the
minimum necessary information to only those we feel need your health care
information. We want to provide health care that is in your best interest.
We also want you to know that we support your full access to
your personal medical records. You may request restrictions pertaining to
parties you do not want PHI released to. You will be asked to authorize release
of PHI to any party that is not directly connected to your treatment, payment,
or health care operations.
If you have any questions, comments, or objections to the
privacy policies on this form, please ask to speak with our HIPAA Compliance
Officer. You have the right to review our entire notice or privacy policies
upon request.
Please sign this form to
acknowledge that you have read this notice of our privacy policies.
BY TYPING YOUR FULL NAME BELOW & TODAY"S DATE, THIS WILL REPRESENT YOUR VALID AND ELECTRONIC SIGNATURE.
Thank you for allowing us to serve you.
