Your health care privacy is my priority and is governed by law. A complete description of your privacy rights and how I protect your privacy is available in print form by request.
Your health record contains personal information about you and your health. This information that is about you, that may identify you, and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. I may use your PHI…
For Treatment: I may use your PHI to provide, coordinate and manage your treatment and care. If I need to consult with other providers, I will only do so with your written permission.
For Payment: I may use your PHI so that we can receive payment for the treatment services provided to you. This will only be done with your written authorization. Examples of payment-related activities are deciding on eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to a lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
Release of PHI With Your Authorization: Uses and disclosures of your PHI not specifically permitted by applicable law will be made only with your written authorization. Any authorizations that you make can be revoked at any time.
As Required by Law: Under the law, we must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purposes of investigating or determining our compliance with the requirements of the Privacy Rule. In addition, I am permitted to use PHI without your permission under certain conditions (listed below) that have to do with your safety, the safety of others, or when required by law. The following is a list of categories where disclosure may be permitted without written authorization.
Child Abuse or Neglect: I am a mandated reporter and may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
Self-harm or the intention to harm others: I may use or disclose your protected health information in a medical emergency to prevent serious harm to yourself or others. If I determine that you may be a danger to yourself, or others PHI may be used as appropriate to keep you or others safe.
Law Enforcement: I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order, or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Concerns, questions, or complaints: If you have any concerns, questions, or complaints you may address them with me directly.
The Practice Policy strives to provide you with the best care possible. My policies are in place to provide quality services that are consistent, thoughtful, and protect your privacy.
Scheduling: In most cases, I will schedule your next appointment with you at a time that works best for you. You can always schedule an appointment by calling my office.
Rescheduling/Cancellation Policy: I require 24-hour prior notification if you need to reschedule or cancel an appointment. You can reschedule or cancel an appointment by calling during or after business hours. If you call after business hours, you can leave a time/date stamped voice message which will serve as a notification. Let me know if you'd like a return call to reschedule your appointment.
Missed Appointment/Late Cancellation Fee Policy: If you cancel an appointment with less than 24-hour notice, or do not show up for a scheduled appointment, you will be responsible for a $125.00 missed appointment/late cancellation fee. This fee will help compensate me for the time saved for you, which could not be used for another patient because of the short notice. I understand that some unusual circumstances (for example, severe weather or illness) can prevent you from showing up for an appointment or canceling within the 24-hour timeline. If you feel that an exception could be made, please discuss the specifics with me.
Insurance and payment for services: I expect payment on the day of your appointment. I have contracted rates with most insurance companies, and with your permission, will file a claim with your insurance carrier for services provided. If you are using insurance to help cover the cost of treatment, the precise fee for your session will be determined by the contracted rate with your insurance company, the length of your session, and the amount of your deductible, co-insurance, or co-pay. You are ultimately responsible for your bill, which means that you are responsible for any amount not covered by your insurance company. If your insurance has been terminated, you will be solely responsible for the charges on your account. To help minimize the chance of insurance denials, I ask that you keep me notified of any changes to your insurance. Balances over 90 days old will need to be made current before you can schedule another appointment.
As of January 1, 2022, I am also required to provide you with a Good Faith Estimate of services and associated costs. After I understand what services you are requesting, I will fill this out, provide you with a copy, and review it with you.