Welcome to Hypospadias Specialty Center. We strive to provide excellent, compassionate service to you and your loved ones. In order to provide this high level of service and better your healthcare experience, we have some policies that we would like to share with you. By signing below, you agree to our policies.

➡We ask that you present your insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance. If you have a change of address or contact information, please notify our office 2 weeks in advance. It is your responsibility to know your plan benefits and verify you are seeing an in-network provider.

➡If we do not participate with your insurance company and you have out-of-network benefits, we can verify those benefits with your insurance as a courtesy to you. You will be expected to make payment in full at the time service is rendered. If your insurance denies our charges or refuses payment for services rendered, the insurance portion will be transferred to the patient portion and billed to the responsible party on the patient’s account. If we do not participate with your insurance and you do not have out of network benefits, please be sure to make private pay arrangements with our office prior to your first visit.

➡We will collect your co-payment, patient responsibility, private pay fees, and/or charge for non-covered services prior to a scheduled procedure. If you have a balance from a previous service, we will also collect that payment. We accept cash, cashiers checks, Visa, MasterCard, Discover, American Express, and check payments for balances under $100.00. Patient care is our top priority, however payment is due for services rendered. If your account becomes delinquent, we reserve the right to refer your account to a collection agency.

➡Insurance Billing: If we participate with your plan, we will bill your insurance for you. Your plan provider can verify if we are in-network with your insurance plan. If your plan requires you to have an authorization to see a specialist, you need to obtain that prior to visiting our office. Your insurance is a contract between you (in some cases, your employer) and your insurance company. We are not a party to that contract. It is very important that you understand the provisions of your policy. If your insurance company pays only a portion of the bill or rejects your claim, any contact or explanation should be made to you, their policy holder. Reduction or rejection of a code or claim which the American Medical Association considers payable does not relieve you of your financial obligation. Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges.

➡Our office uses secure electronic auto-reminders, electronic patient messaging, and secure attachments. Should you wish to opt out of these services, please notify us in writing here.

➡Your health information may be entered into a quality database to assist the physicians in understanding of the patients condition and/or help with medical research. Medical documentation and medical images may be used in publications for educational purposes. This will allow providers to improve in quality care.

➡No show or missed appointments: When an appointment is scheduled with the provider, time is specifically allocated for you. If the appointment is not canceled in advance, we cannot offer that time to another patient. We require a minimum of 48 hours advance notice if you believe you need to cancel or change your appointment. Failure to do so will result in a $50.00 fee applied to your account.

➡Rescheduling Surgery: Due to the large block of time reserved for your procedure, as well as the international nature of our practice, last minute cancellations can create access-to-care problems, as well as significant expenses to our office, the hospital, and the anesthesiologist. If you need to cancel or change your surgery date, please contact our office at least 1 month in advance. If you do not give us notice, and fail to appear for a scheduled surgery date, you will have a $1,000.00 “no-show” fee assessed to your account. If you call to reschedule or cancel a surgery with less than 1 month prior notice, you will be charged a $500.00 change fee. These fees are not covered by insurance and must be paid in full prior to rescheduling the surgery. We understand that extenuating medical circumstances may occur and fees in these instances may be waived subject to management approval.

➡If you have a young child and want to have our staff sit with him during your consultation with the doctor, we are happy to help. By choosing to do so, you agree to release and hold harmless Hypospadias Specialty Center from any and all claims, demands, suits, costs, and/or charges in connection with or arising out of the services we provide. Please note: this is not a babysitting service. Parents are not permitted to leave the premises during consultations.

➡Choice of Law and Forum required provision (HB270): The patient, including patient’s representative and heirs or beneficiaries, and Hypospadias Specialty Center, including the employees and agents, rendering or providing medical care, health care, or safety or professional or administrative services directly related to health care to patient agree: That all health care rendered shall be governed exclusively and only by Texas law, and in no event shall the law of any other state apply to any health care rendered to the patient; and in the event of a dispute, any lawsuit, action, or cause of which in any way relates to health care provided to the patient shall be brought only in a Texas court in the county/district where all or substantially all of the health care was provided or rendered, and in no event will any lawsuit, action, or cause of action ever be brought in any other state. The choice of law and forum selection provisions of this paragraph are mandatory and are not permissive.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, the physician in this practice is a specialist. When we provide treatment we may request that your primary care physician or other specialists share your medical information with us. Also, we may provide your primary care physician and other specialists with information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any. In addition, results of laboratory tests and procedures will be available in your medical record to all
health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations. Your health information may be used as necessary to support the day- to- day activities and management of our practice. For example, information on the services you received may be used to support
budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits
and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us
of your decision to revoke your authorization.

Additional Uses of Information

Appointment Reminders. Your health information will be used by our staff to send you appointment reminders via the
telephone, electronic mail and/or the US mail.
Information about treatments. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health- related products and services that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:
• the right to request restrictions on the use and disclosure of your protected health information
• the right to receive confidential communications concerning your medical condition and treatment
• the right to inspect and copy your protected health information
• the right to amend or submit corrections to your protected health information
• the right to receive an accounting of how and to whom your protected health information has been disclosed right to receive a printed copy of this notice

Practice Duties

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 also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. 

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the receptionist or the Privacy Officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. 

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can contact the Privacy Officer at the address shown below. If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the address shown below. You will not be penalized or otherwise retaliated against for filing a complaint. You may also send a letter outlining your concerns to the U.S.
Department of Health and Human Services.

Contact Person 

The name and address of the person you can contact for further information concerning our privacy practices is: Whitney Wells, Practice Manager

Hypospadias Specialty Center

3716 Standridge Drive Suite 200 The Colony, TX 75056

Effective Date

This Notice is effective on or after 09/02/14.

As our patient, under HIPAA, you have specific privacy rights. We are required by law to attempt to obtain acknowledgement of receipt of “Patient Notice of Privacy Rights”.

We are required to have a notice available for our patients detailing how medical information about you may be used and disclosed and how you can get access to this information. You have a right to review our notice before signing this acknowledgement. A copy of our “Patient Notice of Privacy Rights” is posted in our waiting room and is made available from the receptionist to each patient. The terms of our notice may change. Any change in our notice will be posted in our waiting room.

A summary of your rights includes your right to:

Restrict the use and disclosure of health care information (but your doctor is not required to grant this type of request)
Receive confidential communications in an alternate form or location Inspect, copy, and amend protected health information (you may be billed for the cost of copying) Know about any unauthorized disclosure of protected health information
Have a copy of our patient privacy notice

I acknowledge the receipt of a copy of the “Notice of Privacy Practices” from PARC Urology.

If you would like a copy of our Notice of Privacy Practice, ask our front office for a copy. It is also posted in our lobby.

Personal information includes but is not limited to: Medical history, billing history, recalls, and other correspondences as necessary. Hypospadias Specialty Center will not under any circumstances discuss your personal information with anyone without an authorization from you. We do not need permission from a minor to discuss personal information with a parent or legal guardian.