Prescription Refill Policy
Prescription refills will require an office visit
In order to serve our patients with the highest level of care we will only be refilling prescriptions during an office visit with your provider. This will allow the provider to discuss at length any changes or additional information with the patient at that time regarding your ongoing care. Therefore, we will no longer be refilling prescriptions over the phone or by fax.
Mail order Prescriptions will no longer be faxed, they will need to be mailed by the patient directly
Prescription refills that are mail order will need to be brought to the appointment and will no longer be faxed. Mail order prescriptions once written will need to be mailed by the patient directly to the mail order pharmacy.
Emergency refills, antibiotics, narcotics
If the patient has run out of medication a small quantity will be called in until the patient can visit with their provider. However, antibiotics and narcotics will not be filled without a scheduled appointment.
Insurance Co-pay Policy
Have your insurance card available at each visit. Any applicable co‐pays and deductibles will be due prior to your visit. Remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment.
We accept Visa, MasterCard, American Express and Discover; as well as cash, checks and debit cards. Should you ask us to bill your co‐pay, a service charge of $10.00 will be added. If you should have questions regarding your bill, please call the office or pay your bill online at www.foothillsprimary.com
No Show Fee Policy
We try to see all patients on an appointment basis, and we request that you call 480‐496‐0000 in advance, so we may reserve a time for you. We make every effort to honor all time commitments and request that you extend the same courtesy to us. Occasionally, an emergency may arise, causing delays in our appointment schedule. We will make every attempt to inform you of any extended wait and give you the option of rescheduling at that time.
Please call to advise us of any cancellation (24 hour notice is required) or delays, to avoid a no‐show appointment fee of $50.00. In the event that you are delayed, the provider will be consulted as to whether their schedule will accommodate the delay or if it will be necessary to have you reschedule. We utilize an automated reminder system to remind patients of their appointment prior to their scheduled appointment.
Returned Checks and Non-sufficient Funds Policy
All returned/non‐sufficient funds checks will incur an additional $25 charge.
Financial Policies and Arrangements
We recognize the need for understanding in the areas of payment arrangements and insurance filings. We have put together this sheet to address some of these issues and to advise you of our financial policies.
Insurance - Filing/Benefits/Payments
There are numerous insurance plans with which we have contracted to receive payment directly from the insurance company. With these plans, the patient is generally required to make a co-payment and/or meet a deductible and/or co-insurance. If you are covered by insurance, please show us your ID card. Be prepared to make your co-payment, or pay for your services if your deductible has not been met at the time of service. We accept: cash, checks, money orders and all major credit/debit cards. If you are covered by an insurance plan that is not contracted by our office, you will be asked to pay for all services at the time of service.
We will bill your insurance as a courtesy but you are ultimately responsible for the cost of services rendered. Therefore, it is extremely important that you provide us with accurate and updated information at each visit, so your claim can be properly filed. It is your responsibility as a consumer to know what benefits are covered by your insurance plan. Most insurance carriers have numerous plans that cover many types of services. Some injections, visits & services may not be covered by your particular plan. If you have a question, you should contact member services at your insurance company for specific benefit information prior to you visit. Their phone number should be located on your insurance card. This office can not become involved in prolonged insurance negotiations. If your claim is unpaid after 45 days, you will receive a bill requesting payment in full and you will be responsible for further contact with your insurance company. You will continue to be billed until the balance is paid.
Payment is expected at the time of service. Any balance due on your account must be paid prior to your visit and will be collected in addition to your co-pay. If you do not have your co-pay or payment for your outstanding balance at the time of service, your visit may be rescheduled. Should you ask us to bill your copay, a $10.00 service fee will be added. Payments on balances can be made online.
Bills that are delinquent for more than ninety (90) days will be transferred to an outside collection agency for processing unless prior arrangements have been made with our business office. If you have questions or reason to believe there is an error, please discuss them with us prior to the 90 days.
There is a $25.00 service fee for checks returned for insufficient funds. We will not re-deposit checks and will no longer be able to accept checks for payment. The balance due + service fee must be paid with cash or credit card immediately upon notice of the returned check.
Cancellation of Appointments/No Show Appointments
If you need to cancel your appointment, we require 24 hour notice. If you do not cancel an appointment and no show, you will be charged a $50.00 service fee. Three no show appointments are grounds for dismissal from the office.
Advance Beneficiary Agreement
Medicare and other insurance plans will only pay for services that they determine to be reasonable and necessary under section 1862 (a) (1) of Medicare Law. If they deny payment for services or tests, (i.e. routine exam, testing, labs, vaccinations, injections, procedures, etc) then the patient agrees to be personally and fully responsible for payment.
Please feel free to discuss any concerns you may have with our office staff. Our staff is dedicated to making your visits with us as pleasant as possible.
HIPAA NOTICE OF PRIVACY PRACTICES
FOOTHILLS PRIMARY CARE
Effective Date: September 15, 2006
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION IN COMPLIANCE WITH FEDERAL LAW. PLEASE REVIEW IT CAREFULLY. WE WILL REQUEST THAT YOU SIGN A SEPARATE FORM ACKNOWLEDGING THAT YOU HAVE BEEN GIVEN THE OPPORTUNITY TO READ THIS NOTICE AND THE OPTION TO TAKE A COPY WITH YOU. THE ACKNOWLEDGEMENT WILL BE FILED WITH YOUR RECORDS.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. Protected Health Information (PHI) is information about you, including demographic information that may identify you and relates to your past, present, or future physical or mental health condition and related health care services.
NOTICE OF PRIVACY PRACTICES
We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices. We are required by law to abide by the terms of this Notice of Privacy Practices.
We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. If you wish to obtain a revised Notice of Privacy Practices you may do so by calling the office and requesting that a revised copy be sent to you in the mail, or by requesting a revised copy at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information (PHI)
Your PHI 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. Your PHI may also be used and disclosed to pay your health care bills and to support the operations of the physician’s practice.
Following are examples of the types of uses and disclosures of your health care information that the physician’s office is permitted to make.
Treatment: We will use and disclose your PHI 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 that has already obtained your permission to have access to your protected health information. For example, we would disclose your PHI, as necessary, to a home health care agency that provides care to you. We may disclose PHI to other physicians who may be treating you. For example, your PHI 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. In addition, we may disclose your PHI to another physician or health care provider (e.g. specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, certain types of marketing, research studies as permitted by law, and conducting or arranging for other business activities.
For example, we may disclose your PHI 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 will share your PHI with third party “business associates” that perform various activities (e.g. billing, transcription services, and medical supply vendors) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
Information about treatments: We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Appointment Reminders: We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
2. Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in the reliance on the use or disclosure indicated in the authorization.
You have the opportunity to agree or object to the use or disclosure of all or part of your PHI for the reasons listed below. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine the disclosure is in your best interest. In this case, only the PHI that is relevant to your healthcare will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts for the purpose of coordinating with such entities the uses or disclosures to notify, or assist in the notification of (including identifying or locating), a family member, personal representative of the individual of the individuals locations, general condition or death.
Emergencies: We may use or disclose your PHI in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.
Communication Barriers: We may use and disclose your PHI if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
3. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object.
We may use or disclose your PHI in the following situations without your authorization. These situations include:
As Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your PHI for public health activities and to a public health authority that is permitted by law to collect and receive the information disclosed. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your PHI to a person or company as required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes or other processes required by law, (2) limited information requests for identification and location purposes, (3) processes pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) processes in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the practice’s premises) when it is possible that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaver organ, eye or tissue donation purposes.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your PHI may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility for your treatment, for the health and safety of you or other inmates, for the health and safety of the officers of employees or others at the correctional institution, for the health and safety any individuals and officers responsible for transporting you from one institution to another, and for the administration and maintenance of the safety, security, and good order of the correctional institution.
Required Uses and Disclosures: When required by law, we must make disclosures to you and to the Secretary of the Department of Health and Human Services to investigate or determine our compliance with requirements of the HIPAA Privacy Act.
4. Your Rights:
Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.
You have the right to inspect and copy your PHI. You have the right to inspect and copy your PHI that may be used to make decisions about your care as long as access is not prohibited by state/federal law. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to our medical records department. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies and services associated with your request.
You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI 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 restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you might request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your PHI will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your PHI in violation of the restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by submitting a written request to our office.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request to our Reception Manager.
You may have the right to have your physician amend your PHI.
This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In certain cases, we may deny your request for an amendment. 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 will provide you with a copy of any such rebuttal. Please contact our medical records clerk if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. It excludes any other disclosures which are not required to be documented per the Health Insurance Portability and Accountability Act. You have the right to receive specific information regarding disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You may complain to us or 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 Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer at (480) 496-0000 or by mail at Foothills Primary Care, 600 S Dobson Rd Ste D27, Chandler, AZ 85224
You have the right to obtain a paper copy of this notice from us, upon request.
September 15, 2006