Our Legal Duty
We are required by law to protect and maintain the privacy of your PHI, to provide this Notice about our legal duties and privacy practices regarding PHI, and to abide by the terms of the Notice Currently in effect. We may update or change our privacy practices and policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice on our website at
www.carltonfp.com. You can also request a copy of our Notice at any time. If you are concerned about your privacy rights, or if you disagree with a decision we made about your records, you may contact the Privacy Officer listed below. You may also send a written complaint to the U.S. Department of Health
and Human Services. You will not be penalized in any way for filing a complaint.
Indenmification Clause
I agree to indemnify, defend, protect, and hold harmless the Medical Providers employed Carlton Family Practice; and their resprective officers, Directors, Employees, Stockholders, Assigns, Sucessors and Affiliates (Indemnified Parties) from, against and in respect of all Liabilities, Losses, Claims, Damages, Judgements, Settlement Payments, Deficiencies, Penalties, Fines, Interest and Costs, Expenses Suffered, Sustained, Incurred or paid by the Indemnified Parties, in connection with, results from or arising out of, diretly or indirectly, the Medical Providers employed by Carlton Family Practice; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and phyisical condition, acts of omissions, the medical providers employed by Carlton Family Practice; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the Medical Providers employed by Carlton Family Practice. I am aware of the potential side effects associated with Medical Care and Weight Loss Therapy and accept all the risks involved in taking the medication and will not seek indemnification or damages from the Indemnified Parties.
Contact Information
If you have any questions, requests or complaints, please contact:
Carlton Family Practice, LLC
Attn: April Carlton, APRN
3111 Military Rd
Benton, AR 72015
Email: acarlton@carltonfp.com
Phone #: 501-507-0710
HIPPA
US DHHS
Atlanta Federal Center
Suite 3B70 61 Forsyth Street
Atlanta, GA 30303-8909
Financial Policies & Disclosures
The Financial Policy and Disclosure is to help us provide the most effective and reasonable health care services. Therefore, it is necessary for us to have a Financial Policy and Disclosure stating our requirements for payment for services provided to patient. Patients are responsible for payment of all services provided by Carlton Family Practice. LLC and their associates.
Self-Pay Policies
If you are a Self-Pay patient, you will be required to pay for the office visit before services are rendered and any labs ordered will be paid directly to AR Journey Lab, LLC. In addition, any remaining balance on your account will be collected at discharge.
Insurance Policies
If you are an insurance patient, it is our policy to file for insurance as a courtesy to you, if we have accurate and complete insurance information. If a service is provided that is not covered by your insurance company, you will be the
responsible party at the time of the service. If we have not received a payment from your insurance company within thirty (30) days, you will be responsible for the balance due.
Deductibles, co-payments, and coinsurance will be collected before services are rendered. In special cases, we may need your help in contacting your insurance company for the payment of your services.
Workers Compensation Policies
If you are a workers compensation patient, it is our policy to bill your employer or the workers compensation carrier for services rendered. If you are covered under worker’s compensation, we will accept the payments by the worker’s compensation carrier as per contracted rates based on the mandated AR state fee schedule.
If payment is denied from your worker’s compensation carrier, you will become
responsible for the entire balance of your services. Payment will be due withing ten (10) days following any worker’s compensation payment denial.
It will be your responsibility to contact us with the name and address of your employer or the insurance company that covers your employer.
X-Ray Policies
Iif you require an x-ray on todays visit, the x-ray will be sent out to a Radiologist for a second opinion for quality assurance purposes.
You will be responsible for the cost of this service if your insurance company chooses not to cover it
Overdue & Credit Balance Policies
All over-due patient balances will be sent to collections. All accounts sent to collections will be charged a $25 collection fee in addition to the account
balance.
Credit balances under $15 aged over 60 days may be written off
Divorce and/or Custody Case Policies
The parent or guardian who brings the patient into our office will be held financially responsible regardless of the provisions in the divorce decree or who has custody or who has the insurance.
To help Carlton Family Practice, LLC and AR Journey Lab, LLC to adhere to our policies as outlined
above, we ask that you assist us by:
1. Providing us with current and updated information on yourself and your insurance company
2. Presenting an updated photo identification card and insurance card when changes are made
3. Making the appropriate payment at the time of service, whether it is deductible, co-pay, coinsurance, or the full amount if you are a Self-Pay Patient.
Patient Health Information (PHI) Consent Form Financial Policy & Disclosures
By signing this form, you are giving consent to services and have read & initiated the above terms and conditions.
No Call - No Show Patients
For patients who are registered for an appoint and do not provide notice to our office that they will not be present for their scheduled appointment there will be
A $25.00 FEE
billed to the patient via text or email address on file.