Thank you for choosing Los Angeles Primary Care for your medical care. We are committed to providing you with quality, personal health care, and appreciate your commitment to adhere to our office policy agreement. By understanding our policy, we can provide you with the best service. Agreement with this policy is required for all medical care.
HIPAA We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to our office: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to obtain a paper copy of this notice from us upon request. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the polices and procedures of our office. We will not retaliate against you for filing a complaint. Please contact the following for more information: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W Washington, D.C. 20201 (202) 619-0257 Toll Free: 1-877-696-6775.
HIPPA Acknowledgement. Los Angeles Primary Care is required by law to keep your health information and records safe. This information may include: Notes from your doctor or other healthcare providers, medical history, test results, treatment notes, insurance information . We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared. By signing, you agree to all of the following:
I acknowledge that I have received a copy of Los Angeles Primary Care's HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.
I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.
I understand Los Angeles Primary Care cannot disclose my health information other than as specified in the notice.
I understand that Los Angeles Primary Care reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
Spruce. I consent to communicate with Dr. Sera Ramadan and other staff at Los Angeles Primary Care by email or standard SMS messaging regarding various aspects of my medical care which may include, but shall not be limited to test results, prescriptions, appointments and billing. I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted by a third party.
Financial Agreement: Except as indicated below, payment is required at the time services are provided unless other arrangements have been made in advance. We accept cash, VISA, MasterCard, and Discover credit cards. We require all patients maintain credit card on file in order to book appointments. Cancellations, outstanding charges and additional services as stated below will be charged to the credit card on file. By signing this agreement, you provide consent to any outstanding charges owed and to keep your credit card on file.
Insurance: We are contracted with most insurance plans and will bill your insurance as necessary. If we do not participate with your care plan, payment in full is required at the time of service, unless other arrangements have been made in advance. We may be able to bill your plan as a courtesy to you and credit your account if we receive any additional payment. Knowing your insurance benefits – including eligibility, covered benefits, and medically necessary procedures is your responsibility; please contact customer services at your insurance company for questions you may have regarding your coverage prior to scheduling an appointment. You are responsible for any charges not covered by your plan. By signing this form, you confirm that you are not a currently enrolled in medi-cal/ medi-caid plans, and will be personallly responsible to pay fees depending on services rendered.
Proof of Insurance. All patients must complete and/or update our Patient Information Form at each office visit. You must furnish valid and up-to-date proof of insurance coverage and a copy of your driver’s license. If you provide false or expired insurance information you will be responsible for the balance of the claim. Please notify us of any changes in insurance coverage prior to time of service. Insurance denials for termination of coverage will be automatically billed to you.
Co-payments and Deductibles. All co-payments and unsatisfied deductibles must be paid at the time of service. By contractual law your insurance company requires us to charge for, and you to pay for, all required co-payments, coinsurances, deductible and non-covered services.
Claim Submission. We will submit your insurance claims and assist you in any way reasonable to help get your claim paid. Your insurance company may need you to supply information directly to them. It is your responsibility to comply with their request in a timely manner. Please be aware that the balance of your claim is your responsibility to pay whether or not your insurance company has paid. We are not a party to your insurance contract.
Out of Network Care/ Self Pay: Please be aware that you have an option to seek care from Physicians even though they are not participating in your network. In this situation, your out-of-pocket expense will be greater. As a courtesy to our out-of-network patients, we will file your insurance claim if desired and offer cash prices depending on desired service. This benefit also applies to individuals without insurance. Please call the office at 213-238-5887 for pricing information.
Administrative Charges, Services, and Patient Responsibilities: Due to the continued decline in reimbursements from insurance companies and their failure to pay for the following services, we are no longer able to absorb the cost of these services. Therefore, the following administrative services will be billed directly to you with payment being your responsibility. Our practice is committed to providing the highest quality of service to our patients while keeping our charges for administrative services at or below the usual and customary charges of other medical practices in our area. All such administrative fees must be paid prior to scheduling future appointments. All laboratory and imaging results will require telemedicine follow up. By signing this, I provide consent for my insurance to be billed for all tele-health services rendered to me by the provider. I understand that I am responsible for following up on any laboratory, imaging results, or referrals, if I have not heard a response from the provider after one week of testing date.
Referrals. If your managed care plan requires approval or authorization for referrals to a specialist, radiological imaging, medical facility care, etc., it is your responsibility to inform the office of this requirement prior to referral.
We require 72 hours notice to facilitate a referral request and cannot issue retroactive referrals.
Cancellation Policy: We require 48 hours notice for canceling or rescheduling. Any cancellations with less than 48 hours of notice are subject to a cancellation fee of $100. We recognize the time of our clients and staff is valuable and have implemented this policy for this reason.
Prescription Refills. New prescriptions will not be issued without first seeing your Physician. Prescriptions for acute care or chronic conditions are written with an appropriate number of refills to complete the course of treatment or to
last until your next scheduled appointment. You will be charged $35 for any additional refills issued without seeing the Physician or to replace a lost prescription. All prescription requests are taken only during regular office hours
and filled within 48 hours.
Prescription Prior-Authorizations. We will honor prior authorization requests from the patient, but the patient is responsible for contacting their insurance company to have them forward the prior authorization form to our office. A $75 fee may be assessed for time to complete the prior authorization form. Any request for a forced change in your medication by your insurance company will require an office visit. The patient will need to ask their insurance plan what “alternative medications” are covered and provide a list to their Physician.
Letters / Form Completion. At the discretion of the Physician, letters and forms requiring medical review and Physician signature are subject to a $35 fee.
Telephone Consultations / After Hours Calls. Telephone consultations/after hours calls for medical advice/treatment may be subject to a $35 fee that is billed directly to you. Tele-health appointment rates are determined based on the insurance contract with your carrier.
Requests for Medical Records. In accordance with California law, Los Angeles Primary Care requires written requests for the release of medical records.
I have read, understand, and agree to comply with the terms of your Office Policies.
This form is subject to change without notice.