Initial Patient Consents & Demographics

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Be sure to have your insurance card (if applicable) and state-issued ID.

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Practice Financial Disclosure:

As a service and notice to our patients, Oregon Advanced Surgery is doing business under Oregon Weight Loss Surgery, LLC.

The Practice will submit charges for medical treatment to the patient’s insurance company as Oregon Weight Loss Surgery, LLC. For patients seen under Oregon Advanced Surgery, ALL billing statements, services, and financial notices will be addressed as Oregon Weight Loss Surgery, LLC.

ALL pre-payments for co-insurance, co-pays, and out of-pocket expenses for patients being seen by Oregon Advanced Surgery will be made payable to Oregon Weight Loss Surgery, LLC.

For patients seen under Oregon Weight Loss Surgery, LLC, ALL billing statements, services, and financial notices will be addressed as Oregon Weight Loss Surgery, LLC. ALL pre-payments for co-insurance, co-pays, and out of-pocket expenses for patients being seen will be made payable to Oregon Weight Loss Surgery, LLC.

I understand the Practice Financial Disclosure as declared by Oregon Weight Loss Surgery, LLC and Oregon Weight Loss Surgery, LLC dba Oregon Advanced Surgery.

Patient Responsibility for Payment:

Oregon Weight Loss Surgery, LLC and Oregon Weight Loss Surgery, LLC dba Oregon Advanced Surgery will submit charges for medical treatment to the patient’s insurance company where applicable.

Insurance coverage and benefit packages are an arrangement between patient and insurance carrier. Patients are responsible to be aware of their benefits and to contact their carrier directly if questions arise regarding specific benefits and/or limitations of coverage.

If the patient participates in an HMO or PPO that requires co-payment, the patient MUST pay the co-payment at the time of the appointment.

If the patient has a worker’s compensation claim, Oregon Weight Loss Surgery dba Oregon Advanced Surgery will submit the claim information to the employer’s insurance carrier if the patient provides the practice with the name of the insurance carrier, the date of injury, and if available, the claim number and copy of 801 form. Patient must keep track of their own mileage and prescription costs for reimbursement by the insurance provider.

Uninsured patients will be provided with a Good Faith Estimate (GFE) prior to their service(s) in accordance with federal law.

Any reference our practitioners or staff may make regarding how insurance may pay for a service(s) is an estimation only. We cannot, and do not, guarantee insurance benefits. Regardless of insurance coverage, all services provided are the financial responsibility of the patient.

Patient Responsibility to Provide Accurate Insurance and Demographic information:

I understand that it is my responsibility to provide Oregon Weight Loss Surgery, LLC and Oregon Weight Loss Surgery, LLC dba Oregon Advanced Surgery with accurate insurance and demographic information prior to any services rendered. I understand that, if I have not provided accurate insurance information, I will be treated as a cash pay/uninsured patient. I understand that good faith estimates, reminder calls and other requests prior to a service may not be received if my demographics are not up-to-date.

All Insurances: Assignment of Benefits and Payment Authorization

I authorize payment directly to Oregon Weight Loss Surgery, LLC of all benefits otherwise payable by any insurance policy(s) and I hereby irrevocably assign such benefits to Oregon Weight Loss Surgery, LLC in an amount not to exceed the charges for services rendered. I agree that I am financially responsible for charges denied by insurance. If my indebtedness for such charges is placed with an attorney or agency for collection, I agree to pay Oregon Weight Loss Surgery, LLC reasonable attorney’s fees and the collection agency’s contingency fee, in addition to the balance due.

Co-Insurance, Co-Pays, and Out-Of-Pocket Expenses

I understand that Oregon Weight Loss Surgery, LLC may require me to make pre-payments for co-insurance, co-pays and out-of-pocket expenses related to my primary surgery, all office visits, and subsequent procedures.

Ownership Disclosure

I understand that Dr. Emma Patterson has ownership interest at Wilshire Surgery Center.

No Show & Late Cancellation Policy

I understand that Oregon Weight Loss Surgery, LLC has implemented a 10-minute late and 48-hour cancellation/no show policy for office visits:

1. Late Arrival – Office will accommodate patients who arrive up to 10 minutes late for their scheduled appointment. If a patient arrives more than 10 minutes after the start of their appointment, they may be asked to reschedule.
2. Late Cancel/No Show – We wish to provide our patients with timely scheduling options. Therefore, we require that all patients cancel or reschedule appointments a minimum of 48 hours in advance.
3. Multiple Late Cancel/No Show – After 3 late cancel/no show a patient may be dismissed from the practice or restricted from scheduling with a single provider within the practice.

Patients who arrive more than 10 minutes late to their scheduled appointment, no show or cancel their appointment with less than 48 hours of notice may be charged $100 for their late notice appointment change.

The types of circumstances that may result in the $100 fee being waived include, but are not limited to, the following:

• Inclement Weather
• Illness
• Family member illness
• Personal emergency
• First time, short notice appointment change/late cancel/no show
   

All fees will be added to patient billing accounts and sent on standard billing cycle. 

I understand that Oregon Weight Loss Surgery, LLC has implemented a 3-day/10-day cancellation policy for surgical and endoscopic procedures:

1. Cancellations less than 10 business days prior to procedure will be charged a $100 cancellation fee.
2. Cancellations less than 3 business days prior to procedure will be charged a $200 cancellation fee.
3. Cancellations by your surgeon the day of surgery for noncompliance will result in a $300 cancellation fee. Examples of noncompliance include, but are not limited to, the following:
    - Eating after midnight before surgery
    - Taking medications outside of the patient-specific procedure instructions
    - Not following pre-procedure instructions

This fee must be paid prior to rescheduling your procedure.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete.

Ask us how to do this

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care or payment for your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

 

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