Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Advanced Pediatric Cardiology, PLLC
, we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This is required by the Privacy Regulations created as a result of the Health Insurance Probability and Accountability Act (HIPAA
). This Notice is effective 08/01/2010, and applies to all protected health information as defined by federal regulations.
Understanding Your Health Record/Information
Each time you visit Advanced Pediatric Cardiology, PLLC
, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a 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 document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided,
• A tool in educating heath professionals,
• A source of data for medical research,
• A source of information for public health officials charged with improving the health of this state and the nation,
• A source of data for our planning and marketing,
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Use and disclosure of your health information in certain special circumstances
• To public health authorities and health oversight agencies that are authorized by law to collect information.
• Lawsuits and similar proceedings in response to a court or administrative order.
• If required by a law enforcement official.
• When necessary to reduce or prevent serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to prevent the threat.
• If you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.
• To federal officials for intelligence and national security activities authorized by law.
• To correctional institutions or a law enforcement official.
• For Workers Compensation and similar programs.
• To remind you of needed appointments in the future by way of mailed postcard or email.
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, and make more informed decisions when authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical property of Advanced Pediatric Cardiology, PLLC
, the information belongs to you. You have the right to:
• Obtain a paper copy of this notice of information practices upon request,
• Inspect and copy 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 communications of your health information by alternative means or at alternative locations,
• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Advanced Pediatric Cardiology, PLLC
is required to:
• Maintain the privacy of your health information,
• Provide you with this 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 notice,
• Notify you if we are unable to agree to a requested restriction, and
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve 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 mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you.
We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
For More Information or to Report a Problem, you may contact the practice’s Privacy Officer, Dr. Shabib Alhadheri
or email us at firstname.lastname@example.org
Thank you for choosing Advanced Pediatric cardiology, PLLC
for your care. Your confidence in our services is highly appreciated.
As of August 1, 2013, our office polices have changed. Please read below for the following changes:
Thank you for choosing Advanced Pediatric Cardiology, PLLC
for your cardiac care. We are committed to providing you with the best care possible. Our goal is to provide and maintain a good physician-patient relationship. This Financial Policy helps our practice to provide quality care for our valued patients. In order to reduce potential misunderstandings, our office has clarified our Financial Policy. We require that you read our Policy carefully and agree to comply with it prior to beginning or continuing treatment.
We must emphasize that as a medical care provider; our relationship is with you, our patient, not your insurance company. While the filling of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from THE DATE SERVICES ARE RENDERED. If there is a change with the insurance information, you must inform us immediately. Failure to do so may result in you owing the entire bill. The services generated during your visit are always YOUR RESPONSIBILITY to make sure they are paid for. Payment is due for your outstanding balance as well as co-pay before your visit. According to your insurance plan, you are responsible for any and all co-payments, deductibles and co-insurances. We reserve the right to deny your visit if you do not have payment.
Payment is required at the time of service.
• For patients with private or no insurance, full payment is required at the time of service.
• For patients with HMO plans, co-payment is required at the time of service. The amount of co-payment varies with different plans. You are responsible for knowing the co-payment amount.
• For patients with PPO plan, payment is required at the time of service until the new-year’s deductible has been met. After that, we require co-payments or your liability to be paid at the time of service.
• If you participate with a high-deductible health plan, we require a copy of the health savings account debit/credit card or a personal credit card to remain on file.
• For patients with AHCCCS, the card is required at the time of service. Patients are responsible for payment of services provided if no card is received.
Please be aware that some – and perhaps all – of the services you receive may be uncovered or not considered reasonable or necessary by insurers. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. In the event that your health plan determines that a service is “not covered” you will be responsible for the entire charge. This office is not responsible for disputing decisions made by your insurance carrier regarding coverage. You are due for payment of these services in full at the time of visit.
PROOF OF INSURANCE:
We must obtain a copy of your driver’s license/pictured ID and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information before your visit, you may be responsible for the balance of a claim. It is the patient’s responsibility to provide us with current insurance information and to present an active insurance card at each visit.
We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
PAST DUE PAYMENTS:
Just as we make every effort to accommodate you when you are in need of medical care, we expect that you will make every effort to pay your bill promptly. If you have a financial hardship or if you are unable to pay your bill in its entirety please contact our billing office to discuss payment options. We reserve the right to report delinquent balances to credit bureaus, assess a collection fee, and/or take other collection action
. Therefore, if your account is over 60 days past due, you will receive a statement stating that your balance will go to collections. Please be aware that if a balance remains unpaid, we will then refer your account to a collection agency unless other arrangements have been made. Any fees imposed in the collection of your account are the guarantor’s responsibility and may be recovered in a courtroom, along with any associated court and attorney’s fees. Accounts that are turned over to collections may result in dismissal from the practice.
First billing statement is free. Thereafter, there will be a $5.00 statement fee for each additional statement sent out. Please update our office with a valid address. Failure to do so could result in multiple statements getting sent out with additional fees which you are responsible for.
FORMS OF PAYMENTS:
We accept Visa, MasterCard and Discover Cards, as well as cash and personal checks. WE DO NOT ACCEPT AMERICAN EXPRESS.
We are happy to offer a discount to our patients who are uninsured. Payment is expected at the time of service if you are uninsured. If you find you need a payment plan, please feel free to discuss this with our staff, preferably before services are rendered to make the appropriate arrangement. PLEASE BE ADVISED THAT A CREDIT CARD ON FILE WILL BE REQUIRED FOR ALL PAYMENT PLANS.
A $20 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.
NO SHOWS/CANCELLATION POLICY:
Missed appointments represent not only a cost to us, but also an inability to provide services to others who could have been seen in the time set aside for you. Notification allows the doctor to see another patient who needs to be cared for that day. We require 24-hour notice of cancellation to avoid a $75 cancellation fee. We will inform you of this policy when the appointment is made. It is your responsibility to remember your appointment. We may charge your credit card on file if you do not call and cancel your appointment within the allowed time frame.
Our practice must receive a referral from your Primary Care Provider before your appointment if required by your insurance.
CHILDREN OF DIVORCED/SEPARATED PARENTS
The parent and/or legal guardian who brought the child in for medical service will be required to pay for the bill. We do not bill third parties regardless of what the decree or custody documents indicate. Please make appropriate arrangements prior to the office visit.
“Joint Custody” means that each parent has equal access to the medical record. Without a court order, we will not stop either parent from looking at their child’s chart, discuss what each parent told the doctor when they were here last, and notify the other parent when a child is being treated, or call the other parent for consent prior to treatment.
We thank you for understanding our financial policy. Our goal is to make your visit with us pleasant and professional. If you have any questions about the above information, please do not hesitate to ask a member of our staff.
Thank you again for choosing Advanced Pediatric Cardiology for your heart care.