Once your information is reviewed and eligibility determined, you will receive a link schedule your examination and consultation with Dr. Rami. If any further steps are required beforehand, I will help you navigate that process.
PPO Plans:
- No referral is needed.
- Charges may be applied as a Copayment and/or Deductible charge depending in your insurance plan and will be billed to you after your visit if applicable.
- I am a Participating In-Network Provider for Aetna, Blue Shield of CA, Anthem Blue Cross, Blue Cross / Blue Shield, Cigna, United Healthcare, and Medicare.
HMO Plans:
- A referral from your PCP/health plan is required
- Use this referral address: 700 S Flower St., Suite 1000, Los Angeles, CA 90017
- Your referral/authorization must include these codes: 99204, 31231, 92550, 92552
- Fax your referral to (323) 983-0888 prior to your visit
Patient Care Agreement
1. Parties
This Agreement is between Dr. Rami MD Med Corp ("Physician" or "Practice") and the individual identified as the "Patient."
2. Services
The Physician agrees to provide medical and non-medical services ("Services") within their scope of practice. These include:
- Consultation & Examination: Subject to availability.
- Case Record: Includes findings, assessment, and treatment plan.
- Prescriptions: For labs, studies, medications, or consultations. Services from hospitals, ERs, radiology, and outside labs are not included unless part of a paid package.
3. Insurance
- Authorization: Before your appointment, confirm insurance covers the following CPT codes: 99204, 31231, 92550, 92552.
- PPO: No referral required. You are responsible for any copays or deductibles.
- HMO: A referral from your PCP is required and must include the codes above.
- Patient Responsibility: We bill insurance, but you are responsible for any unpaid costs.
- Verification: You must verify insurance coverage. We assist with records and appeals if needed.
4. Fees and Payment
- Consultation Fee: Current same/next-day rate is $650 (subject to change).
- Fee Schedule: Available upon request.
- Payment: Due in full upon invoice. Credit/debit cards accepted.
- Cancellation Fee: $150 for appointments canceled less than 24 hours in advance.
- Late Payment: 10% fee every 30 days past due. Contact us if needed.
5. Communications
Orella, Inc.
700 S Flower St, Suite 1000, Los Angeles, CA 90017
Phone: (323) 655-6222 | Fax: (323) 983-0888 | Email: admin@orellahealth.com
- Email: Use for general questions. Sensitive information should go through our secure portal.
- Confidentiality: Email is not fully secure.
- Emergencies: Do not email. Call 911 or go to the ER.
- GenAI Disclosure: If AI-generated communication is used, you will be notified (see Section 22).
6. Designated Physician
The named Physician provides all services. A qualified covering provider may assist if unavailable.
7. Appointment Scheduling
Scheduled on a first-come, first-served basis unless urgent medical need is determined.
8. Term and Termination
This Agreement is active while care is ongoing.
Either party may terminate:
- Patient: At any time or if relocating.
- Practice:
- For breach not corrected within 10 days.
- For nonpayment over $100 not resolved within 10 days.
- With 30 days written notice.
This Agreement ends upon the death or dissolution of either party.
9. Dispute Resolution
Please raise concerns with staff first. If unresolved, mediation is encouraged. If that fails, disputes go to binding arbitration under the American Arbitration Association in Los Angeles County, CA.
10. Independent Medical Judgment
The Physician's independent medical judgment is not influenced by this Agreement.
11. Terms of Usage
The Practice may issue additional Terms of Usage in writing, which will take precedence if there is conflict.
12. Change of Law
If laws materially change this Agreement, either party may request renegotiation or terminate after 30 days.
13. Severability
If any part of this Agreement is invalid, the rest remains effective.
14. Notice
Written notices must be sent by fax, courier, or certified mail to the addresses listed here.
15. Amendment
This Agreement may be amended in writing by both parties. The Practice may also amend it to comply with law with 30 days' written notice.
16. Assignment
The Patient may not assign this Agreement to another party.
17. Legal Significance
This is a legal agreement. By signing, you acknowledge having had the chance to seek legal advice.
18. Governing Law / Arbitration
This Agreement is governed by California law. Both parties waive jury trial rights.
19. Waiver
A party’s failure to enforce a provision is not a waiver of that provision.
20. Service
Notices are considered served when mailed to the address on file via first-class mail.
21. Entire Agreement
This is the full and final agreement, replacing any prior understandings.
22. Generative Artificial Intelligence (GenAI)
The Practice may use GenAI to assist in generating patient communications. When GenAI is used for clinical messages, you will be notified. This does not apply when content is reviewed by a licensed provider. You may opt out of GenAI use by informing the Practice.
HIPAA Notice of Privacy Practices
Effective Date: March 1, 2025
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.
Orella Health is committed to maintaining the privacy of your health information. This Notice explains how we may use and disclose your Protected Health Information (PHI) for treatment, payment, and healthcare operations, as well as your rights regarding your PHI.
What Is PHI?
Protected Health Information (PHI) refers to any information that identifies you and relates to your health condition, healthcare received, or payment for care.
1. How We May Use and Disclose Your PHI
For Treatment:
- Coordination with other healthcare providers
- Referrals to specialists, diagnostic labs, or imaging centers
For Payment:
- Billing your insurance or collecting payment from you
- Determining coverage or eligibility
For Health Care Operations:
- Quality improvement and internal audits
- Training healthcare students or staff
- Business support services (e.g., transcription, IT)
Additional Uses Without Authorization (when permitted or required by law):
- Public health activities (e.g., disease reporting)
- Cases of abuse, neglect, or domestic violence
- Health oversight and regulatory compliance
- Legal proceedings (e.g., court orders, subpoenas)
- Law enforcement (e.g., locating a suspect or victim)
- Organ donation or funeral arrangements
- Approved research under privacy safeguards
- Serious threats to health or safety
- Military, national security, and correctional needs
- Workers' compensation claims
Uses Requiring Authorization:
All other uses and disclosures not covered in this Notice require your written authorization. You may revoke an authorization at any time in writing.
Disclosures with Opportunity to Agree or Object:
Unless you object, we may:
- Include basic information in facility directories
- Share PHI with individuals involved in your care or payment for care
2. Your Rights Regarding PHI
Right to Inspect and Copy:
You may request to review or receive a copy of your medical records and billing information. Reasonable fees may apply. Certain limitations apply (e.g., psychotherapy notes).
Right to Request Restrictions:
You may request limits on certain uses or disclosures. We are not required to agree, except where you pay out-of-pocket in full for a service and request that information not be shared with your health plan.
Right to Confidential Communications:
You may request that we contact you at specific locations or via specific methods.
Right to Amend:
If you believe your record is incorrect, you may request an amendment. If denied, you may add a written statement of disagreement to your record.
Right to an Accounting of Disclosures:
You can request a list of certain non-routine disclosures made in the past six years. Disclosures for treatment, payment, or operations are not included.
Right to a Paper Copy of This Notice:
You may request a printed copy at any time, even if you received this electronically.
3. Filing a Complaint
If you believe your privacy rights have been violated, you may file a complaint with:
Privacy Officer
Orella Health
700 S Flower Street, Suite 1000
Los Angeles, CA 90017
Phone: (323) 655-6222
Email: admin@orellahealth.com
You may also file a complaint with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
This Notice may be updated periodically. You may request the most current version at any time or view it at www.orellahealth.com.