Greensboro Medical Associates-New Patient Forms

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR MY MEDICAL CARE. MY INSURANCE WILL BE FILED AS A COURTESY.

Greensboro Medical Associates- HIPAA Authorization Form

Please complete this authorization to allow Greensboro Medical Associates to disclose your health information as specified below.

Greensboro Medical Associates, P.A.

Financial and Release of Records Policies

Agreement and Acknowledgement

• Insurance co-pays are due at the time of your appointment.  Your insurance policies may require you to make a copayment or pay a deductible for an office visit, a diagnostic test and/or a procedure; therefore, payment is expected on the date of service.
• Our office accepts many health care plans.  We will bill those plans with which we have an agreement and collect co-pays and deductibles at the time of service.  In the event that your insurer determines the service is “not covered” by the terms of your health care plan, you will be responsible for payment in full on the date of service(s) to include office visits and procedures.
• In the event that our physician(s) are not enrolled with your health care plan, you will be responsible for payment in full on the date of service(s).  In this instance, you may submit your claim directly to your carrier to request reimbursement.
• In the event that your medical expenses will not be submitted to an insurance carrier, payment is due at the time of service to include office visits and procedures.
• Many insurance companies require an authorization for visits to receive full benefit coverage.  If you are unsure if authorization is required, please call your insurance carrier directly.  If required, the authorization must be received before your visit.  Failure to provide us with the proper authorization may result in the rescheduling and/or cancellation of your appointment.
• For appointments that are missed and not cancelled at least 24 hours prior to the scheduled office visit, there will be a $25 no-show fee charged.
• Form fees are not covered by your insurance company.  Therefore, there will be a $25 charge for each form.  This is to be paid in advance.  A physician may complete one form at no charge during an office visit.
   

Financial Agreement

I hereby assume full responsibility for all charges incurred for professional services rendered by Greensboro Medical Associates, P.A. and its assistants, including 33 1/3% collection costs, unless the services are deemed “paid in full” as a result of a contractual agreement between Greensboro Medical Associates, P.A. and my insurer. 

 

Authorization for the Release of Information

I hereby authorize Greensboro Medical Associates, P.A. to release any medical, psychiatric, infectious disease (including AIDS confidential information) or drug and/or alcohol related information to my referring physician and any insurance company with whom I have medical benefits for the purpose of filing a medical claim.  I acknowledge that this authorization is valid until such time as all medical bills related to my treatment have been paid.  I further understand that I can withdraw this consent for release of information at any time prior to this expiration date except to the extent that action has been taken in reliance hereon.

 

Group & Individual Insurance, Assignment of Benefits

I authorize my health insurance benefit plan to pay directly to Greensboro Medical Associates, P.A. for services rendered.  I understand that I am financially responsible to Greensboro Medical Associates, P.A. for charges not covered by this assignment.

 

I acknowledge that I have read and agree to the financial and privacy policies of Greensboro Medical Associates, P.A.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

ABOUT THIS NOTICE

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and our Business Associates’ 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.

We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information. 

 

USES 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 students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students who 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 your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your protected health information 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 situations 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, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ 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 from using or disclosing 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 or disclosure indicated in the authorization.

 

YOUR RIGHTS

The following are statements 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 who 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 us even if you have agreed to receive the notice electronically. We will also make available copies of our new notice if you wish to obtain one.

We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.

 

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.

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 Officer in person or by phone at our main phone number.

Please sign the accompanying “Acknowledgment” form.

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

 

I acknowledge that I have received a copy of Greensboro Medical Associates, P.A.’s “Notice of Privacy Practices” for protected health information on the date set forth below.

FOR USE BY Greensboro Medical Associates, P.A. PERSONNEL ONLY (complete if patient acknowledgement is not obtained)

An Acknowledgment of Receipt of Notice of Privacy Practices was not received because:

At Greensboro Medical Associates, we value your time and are committed to providing high-quality care. When you miss an appointment without notice, it prevents us from offering that time slot to another patient who needs it. To help everyone get the care they need, we have established the following policy.

 

Definitions
·  No-Show: Failure to attend a scheduled appointment without prior cancellation.

·  Same Day Cancellation: Cancelling or rescheduling an appointment with less than 24 hours' notice.

·  Late Arrival: Arriving more than 15 minutes after the scheduled appointment time.

Policy & Procedures
·   We require 24 hours’ notice for appointment cancellations or rescheduling.

·   No-Show for three or more appointments may result in dismissal from the practice.

Late Arrivals
·   If you arrive more than 10 minutes late, it will be at the provider’s discretion whether to proceed with the appointment.

·   If you arrive 15 minutes or more late, you may be considered a no-show and will likely need to reschedule.

New Patient
·  If a new patient misses their first scheduled appointment without proper notice, they will be assessed a $100.00 no-show fee. One reschedule will be permitted upon receipt of payment.

No-Show Fees
·  No-Show & Same Day Cancellation: $25.00

·  Late Arrival: Assessed on a case-by-case basis. A late arrival fee will only be applicable if the provider is unable to see you.

·  New Patient No-Show: $100.00

Payment of Fees
·  No-show and cancellation fees are the responsibility of the patient and are not covered by insurance.

·  All fees must be paid in full before your next appointment at the time of reschedule. These fees cannot be set up on a payment arrangement and will be billed to you if they go unpaid.

·  Patients with repeated cancellations or no-shows may be discharged from the practice. In that case, we will provide emergency care for 30 days while you find a new provider.

 

We Appreciate Your Cooperation as your health and satisfaction are important to us. We value your trust and ask for your understanding as we strive to provide timely care to all patients.