Southside Foot Clinic PC

When necessary, we will contact you at your phone#, cell phone#, and if necessary Emergency Contact phone#. If we are unable to reach you we will leave a voicemail.

TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)

I ACKNOWLEDGE THAT I WAS OFFERED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I HAVE READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTAND THE NOTICE.
IF YOU WOULD LIKE TO READ A COPY OF THE NOTICE OF PRIVACY PRACTICES, PLEASE ASK AT THE CHECK-IN DESK.

Thank you for choosing Southside Foot Clinic as your healthcare provider. We are committed to the successful treatment of your condition. Your clear understanding of our financial policy is important to our professional relationship. Please call our office if you have any questions at 317-882-9303.

As a courtesy, we will bill your insurance directly; however, we must have a copy of your current insurance card. Failure to provide us with correct insurance information could result in the full amount of charges becoming patient responsibility. We are required by certain insurances to file a claim within a specific amount of time, so it is crucial that we receive the correct information immediately.

If payment is not received from the insurance carrier or other responsible party in 60 days, we have the right to bill you directly. It is your responsibility to make sure that these claims are paid in a timely manner. This also pertains to secondary insurances. We send a copy of your primary insurance company's EOB with EVERY claim to a secondary. If they deny for lack of information, it is the patient’s responsibility to give them that information. We do NOT bill tertiary insurances as of June 1, 2014.

If you do not have insurance, or if you do not have your insurance card, full payment is due at the time of service. We accept cash, check, and VISA/MasterCard/Discover/American Express.

All patients must complete the registration form and other related documents.

The adult/guardian who signs this financial policy will be responsible for the balance on the account.

Please notify us immediately of any changes in your insurance coverage.

Requests for copies of medical records and x-rays must be made at least 10 business days in advance. There is a fee for these records being expedited. Fees for these forms and records must be paid prior to receipt of any requested papers. These fees are not covered by your insurance. 

There are fees for FMLA and Workers comp forms. Fees for these forms must be paid prior to receipt of any requested forms. Fees 1-3 pages $15, over 3 pages $25. These fees are not covered by your insurance.

No show/late cancellations: there will be a $25 no show/late cancellation fee for all appointments that are not rescheduled or canceled within 24 hours of the appointment. There will be a $150 fee for missed surgery appointments. This is not covered by your insurance company. There will be a billing fee of $15 added to all dates of service where the co-pay was not paid within 1 (one) week of an appointment. Copays are due at time of service.

Medicare
We are participating physicians with Medicare. This means that you will be responsible for 20% of the approved Medicare fee, the yearly deductible (if applicable) and full payment of any non covered services. There may be occasions when you will be asked to sign a waiver for any non covered services that may not be covered under these plans.

Medicaid/Anthem HIP
We are not credentialed with Medicaid. We are not part of the HIP program with Anthem. We do not file claims with Medicaid or HIP. You will be responsible for any balance not covered if it is your responsibility. This means that if you would like to be seen here, payment is due in full at time of service. Since we are out-of-network with this program, we cannot bill HIP or Medicaid for your claim. You must understand that you will not be reimbursed by them, if seen in our office.

HMO/PPO/EPA/HDHP
We are members of most, but not all plans. You are responsible for verifying that the physician is in your network. HMO members – please note: You must have your referral at the time of your visit or your plan requires that we ask you to reschedule. You are responsible for referrals and any non-covered services

Self Pay - Full payment is due at the time of service unless prior arrangements have been made.

DISCLOSURE OF FINANCIAL INTEREST
Pursuant to Ind. Code. Ann. § 25-22.2-11-3. Indiana law requires physicians make the following disclosures to a patient when they refer a patient to a health care entity in which the physician has a financial interest. In the event that you undergo surgery in an ambulatory surgery center, a separate charge will be made by that facility. Your podiatric physician at the Southside Foot Clinic may have a financial interest in; a surgery center where you will be having your surgery, Franciscan Surgery Center or Community Surgery Center; EBM Medical; and Central Indiana Vascular Clinic. You may choose to be referred to another health care entity.

Usual and Customary Rates(UCR)

We are committed to providing you the best treatment possible. Our charges are “usual and customary” for our area. If we do not have a contract with your insurance company, you are responsible for payment in full, regardless of any insurance company’s arbitrary determination of UCR.

Financial Agreement
I understand that if the office agrees to bill insurance as a courtesy, I must submit information as needed to ensure that payment for services rendered is received. I understand that I am ultimately responsible for payment of all services. I will pay any unpaid balance by cash, check, or credit card (VISA/MasterCard/American Express/Discover). For accounts to stay in good standing, a payment must be made on it every 30 days. Every effort will be made to work with our patients on delinquent accounts, but if the account is in default it will be turned over to a collection company where you could be responsible for collection effort fees, including interest, attorney fees and court costs.

Southside Foot Clinic, PC promotes a doctor-patient relationship that is based on trust, focusing on patients as individuals. The Doctor’s and our outstanding support staff strive to be fair and courteous in all of our dealings.

The following policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-shows, reschedules and late cancellations cause problems that go beyond any financial impact to our practice. When an appointment is made or a surgery is scheduled, it takes an available time slot away from another patient in need of medical care. Not canceling an appointment or a scheduled surgery in a timely fashion is unfair to other patients, some of whom may be quite ill and may unnecessarily delay the delivery of health care. For these reasons we have developed the following No show/Reschedule/Late Cancellation policy.

Policy for No-show/Reschedule/Late Cancellations of Appointments

• A no-show is defined as missing a scheduled appointment without calling us in advance to cancel the appointment. A late reschedule/cancellation is defined as failing to cancel or reschedule a scheduled appointment the day before your scheduled appointment. The fee is $25. We request that if you need to cancel or reschedule your appointment, you must contact our office no later than 24 hours before your scheduled appointment so that we may offer the appointment time to another patient who is in need of medical attention.
• We understand that everyone might have unforeseen events in which you cannot make your appointment with us, so we have allotted you one grace appointment each calendar year for that sudden emergency.
• Finally, we understand that circumstances beyond your control may arise, where adequate notice is not possible. These limited situations will be considered on a case by case basis
• A patient may NOT cancel their appointment via text message, email or with our answering  service.
• Please understand that the intent of this policy is to aid us in offering a high standard of care to our patients and that this policy is in place to help us achieve that goal. We pledge to do our part to keep our schedule moving as efficiently as we possibly can. We value you as a patient and appreciate your understanding and cooperation. 

Policy for No-show/Reschedule/Late Cancellations of Surgeries

• The same as above but with the following exceptions:
   o Any Reschedule/Late Cancellation must be made 48 hours in advance
   o The charge for a No-show is $150 and there is no grace appointment

I acknowledge that I have read and understand this No show/Reschedule/Late cancellation policy. I further understand that after my 2nd No-show/Reschedule/Late cancellation, I could be dismissed as a patient from the practice.

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI purposes that are permitted or required by law. It also describes your rights to access and control your protected health information (PHI). “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required 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. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

How this Practice Protects Your PHI:

• Your PHI may be used and disclosed by staff members involved in your care and treatment for the purpose of providing health care services to you. Your PHI may be used and disclosed to pay your health care bills and to support the operations of your doctor’s practice such as coordinating your care.
• Your PHI may be used or disclosed as require by law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
• Your PHI may be disclosed for public health activities and purposes to the public health authorities that are permitted by law to collect or receive information such as preventing or controlling disease, injury or disability.
• Your PHI may be disclosed if authorized by law, for the purpose of exposure to a communicable disease or otherwise a risk of contracting or spreading the disease or condition.
• Your PHI may be disclosed to agencies authorized by law for audits, investigations, and inspections such as government agencies that oversee the health care system, government benefit programs and other civil rights laws.
• Your PHI may be disclosed to a public health authority authorized by law to receive reports of child abuse or neglect. In addition, we may disclose 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.
• Your PHI may be disclosed to authorized person or company by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of the FDA-regulated products or activities such as tracking products, enable product recalls, or conduct post marketing surveillance as required by law.
• Your PHI may be disclosed in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, or conditions in response to a subpoena.
• Your PHI may be disclosed as applicable legal requirements are met, for law enforcement purposes such as locating a suspect, fugitive, material witness or missing person.
• Your PHI may be disclosed to a funeral director, coroner or medical examiner for identification purposes, determining cause of death or to perform duties authorized by law.
• Your PHI may be disclosed for research purpose when this has been approved by an institutional review board.
• Your PHI may be disclosed when appropriate conditions apply, for individuals who are Armed Forces personnel, as deemed necessary by appropriate military command authorities, by the Department of Veterans Affairs, to foreign military authorities if you are a member of that foreign military service, for the purpose of conducting national security and intelligence activities including provisions of protective services to the President or others legally authorized.
• Your PHI may be disclosed to comply with workers’ compensation laws.
• Your PHI may be disclosed if you are an inmate of a correctional facility and your doctor created or received your PHI in the course of providing you care.
• Other use and disclosure of your PHI will be made only with your written authorization unless otherwise permitted or required by law. You may revoke this authorization in writing at any time. If you revoke your authorization, we will not use or disclose your PHI for the specifications of the written agreement.
• You have the right to inspect and copy your PHI about you for as long as we maintain the PHI. You may not inspect or copy psychotherapy notes, information compiled in anticipation of a civil or criminal proceeding, laboratory results that are subject to law, research that you signed your authorization rights for trial programs. As permitted by federal law, we may  charge you’re a reasonable copy fee for a copy of your records.
• You have the right to request a restriction of your PHI for the purpose of treatment, payment or health care operations when payment for the treatment has been made in full from out of pocket expense. You may also request PHI not be disclosed to family members or friends who may be involved in your care. Your doctor is not required to agree to a restriction that you may request.
• You have the right to request to receive confidential communication by alternative means or locations.
• You have the right to have your doctor amend your PHI, in certain cases we may deny your request for amendment.
• Your PHI cannot be used for marketing products and services without authorization from you.
• You have the right to receive an accounting of certain disclosures we have made, if any, on  your PHI. This excludes disclosures we may have made for you if you authorized us to make the disclosure, for participating doctors who consult or assist with your care, for national security or other law enforcement disclosures.
• You have the right to complain to us or to 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. We will not retaliate against you for filing a complaint.

You may contact our Privacy Officer: KIRK LEMOINE / WENDY WINCKELBACH, DPM  

Contact Information: (317) 882-9303

This notice was published and becomes effective on: SEPTEMBER 23, 2013