COLON AND RECTAL SURGEONS OF GREATER HARTFORD
Dr. Robert Lewis, Dr. Daniel Mullins, Dr. Andrew Raissis, Dr. Rachel Scott,
Dr. Vanessa Baratta, Dr. Jonathan Chang, Ly Tran PA-C,
Meghan Dolan PA-C, Ann Navage APRN, CWOCN
6 Northwestern Drive Suite 305 Bloomfield CT 06002
2400 Tamarack Ave Suite 200 South Windsor, CT 06074
Phone -860-242-8591 Fax – 860-242-2511
WWW.CRSGH.COM
PATIENT INFORMATION & OFFICE POLICIES
HIPAA NOTICE OF PRIVACY PRACTICES
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.
We are required by law to maintain the privacy of your protected health information (PHI) and to provide you with this notice of our legal duties and privacy practices. Please call 860-242-8591 with any questions.
How We May Use and Disclose Your Information
We may use and disclose your health information for the following purposes:
• Treatment: To provide, coordinate, or manage your health care.
• Payment: To obtain payment for services provided to you.
• Healthcare Operations: For activities necessary to run our practice (quality assessment, staff training, compliance).
We may also disclose your information:
• When required by law
• For public health activities
• For health oversight activities
• In response to court orders or legal proceedings
Your Rights
You have the right to:
• Inspect and obtain a copy of your medical records
• Request corrections to your records
• Request restrictions on certain uses/disclosures
• Request confidential communication
• Receive an accounting of disclosures
Our Responsibilities
We are required to:
• Maintain the privacy of your information
• Provide you with this notice
• Notify you of any breach of unsecured PHI
SIGNATURE ON FILE AUTHORIZATION
• I authorize the release of any medical information to my insurance carrier as requested by them. I understand that the specific type of information to be released includes my diagnosis, prognosis and treatment for physical illness, and, where applicable, mental health, alcohol or drug abuse, HIV test results, or AIDS or any AIDS-related diagnosis. I permit a copy of this authorization to be used in place of the original. This authorization will remain in force and effect until revoked by me in writing
• Medicare/Medicaid patients - I authorize any holder of medical or other information about me to be released to the Social Security Administration and Health Care Financing Administration of its intermediaries or carriers, any information needed for this or related Medicare/Medicaid claim. I permit a copy of this authorization to be used in place of the original, I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment.
• I authorize any medical benefits payable to me to be paid directly to Colon and Rectal Surgeons of Greater Hartford.
• I recognize and accept personal responsibility for immediate payment of charges determined to be copay, coinsurance, deductible, not covered or otherwise determined to be my responsibility by my insurance plan and agree to pay attorney’s fees, court costs and a 15% collection fee if turned over to a collection agency, should I fail to make payment.
FINANCIAL DISCLOSURE POLICY
Insurance:
• We participate with many insurance plans. It is your responsibility to verify participation status and coverage requirements as outlined by your specific policy.
• Copayments are due at the time of service. Failure to pay your copay may result in cancelation/rescheduling of your appointment
• Any balance deemed patient responsibility as determined by your insurance plan is due upon receipt. Any balances that remain unpaid are subject to be referred to an outside collection agency & are subject to a 15% collection fee which will be added to the balance referred.
Referrals & Authorizations
• If your insurance requires a referral, it is your responsibility to obtain it prior to your visit/procedure
• Failure to obtain required referrals may result in cancelation/rescheduling of your visit/procedure
Procedures performed at an ASC, hospital or other facility
• Each entity involved in your care will bill separately for their services including but not limited to
o Physician bill
o Facility bill
o Anesthesia bill
o Pathology bill
Missed Appointments
• We require at least 24-hour notice for cancellations of scheduled office visits, failure to do so will result in a $25.00 fee.
• We require at least 48-hour notice for cancellation of scheduled procedures, failure to do so will result in a $100.00 fee.
• We require at least 48-hour notice for cancellation of scheduled surgeries, failure to do so will result in a $200.00 fee.