Sonoran Spine transmits prescriptions electronically (except those that must be handwritten by law) to your pharmacy. Which pharmacy will you be using for any prescriptions from us? 

I hereby acknowledge that I can revoke the authorization to the above mentioned individuals at my discretion with a written notification to Sonoran Spine.

Welcome to Sonoran Spine. We want to make you aware of our policy regarding health insurance.

It is the responsibility of our insured patients to be aware of their health insurance benefits and restrictions prior to visiting our facility. This would include copayments, deductibles, coinsurance, authorization/referral requirements, policy exclusions, and pre-existing condition restrictions.

As a courtesy to our patients, our office will verify your eligibility prior to your visit. Please be aware that the insurance always has a disclaimer stating that “this does not guarantee payment for services – the claim will be subject to policy benefits and restriction once the claim is received”. Therefore there is no way we can be 100% certain they will pay part or all of your claim.

If your visit requires pre certification or a referral, it is the patient’s responsibility to obtain this from the primary care physician or insurance company directly.

If our patients require surgery, we will do our best to make sure we use a contracted facility and that precertification is obtained if necessary. If you have not met your deductible or your out of pocket maximum benefit, a deposit may be required prior to your surgery. If so we will discuss this prior to your surgery to avoid cancellations.

Please know that we do our best to provide you with the most accurate information available to us but it is ultimately the patient’s responsibility for any charges incurred. If you disagree with the way the insurance has processed your claim, please contact your insurance company.

I understand that I am responsible for any charges incurred that are not covered by my insurance carrier.

Our commitment to your privacy
Our practice is dedicated to maintaining your privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following information.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our business associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “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 condition and related health care services.

USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff and others outside of
our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay
your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment,
employee review, training of medical student, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose you protected health information, as necessary, to contact you to remind
you of your appointment, and inform you about treatment for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in. We may use or disclose your protected health information in the following situation without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health
oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroner, funeral directors, organ donation, research, criminal activity, military activity and national security, worker’s compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the
requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or
disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use of disclosure indicated in the authorization.

YOUR RIGHTS
The following are statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or
electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used, in a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends you may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures; pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from even if you have agreed to receive the notice electronically We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS
You may 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 Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

HIPAA COMPLIANCE OFFICER 

Susan Dylo

480-962-0071

practiceadministrator@sonoranspine.com

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Office in person or by phone at our main phone number.

Please sign the accompanying “Acknowledgement” form. Please note that by signing the Acknowledgement form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Your surgeon may consult for companies and engage in implant design and research. If these products are approved by the FDA and appropriate for use in your surgery, they may be used.

Your surgeon may have an ownership stake in a facility where you receive healthcare. You can choose a different center if that is your desire.

Your surgeon may have an ownership stake or other participation in manufacturing companies that design and make spinal implants. If these products are approved by the FDA and appropriate for use in your surgery they may be used. If this is a concern for you, please consult with your surgeon before your procedure.

Your surgeon may elect to use an FDA approved product in an “off Label” way, if it is judged to be more beneficial to your surgery’s success than other methods. An example may include screws in the back of your cervical spine for stabilization.

Your surgeon may have a relationship with the distributor who provided the spinal instrumentation or other medical product.

Bone morphogenic Protein (BMP) has been FDA approved but it is commonly used “off label” to help the spine heal in fusion procedures involving the spine. Your surgeon may elect to use this FDA approved fusion enhancement technology in an “off label” way, if it is judged to be more beneficial to your surgery’s success than other methods.

If you have any concerns with the information above, please feel free to discuss them with your surgeon prior to your surgery.

Sonoran Spine Center, PC

Please sign below to acknowledge you have read and consent to the above: