Gastroenterology Specialist, INC
3355 Burns Rd, Suite 306
Palm Beach Gardens, FI 33410
PH: 561-630-8775

The Health Insurance Portability and Accountability Act require that we disclose certain information to our patients regarding the privacy of their medical information and records: as well as our policies regarding the treatment of this information.

Your medical information, records and documents are of a highly confidential nature. In the course of providing services to you, this office will create, receive and store health information that identifies you. Alt is often necessary to use and disclose this health information in order to treat you, to obtain payment for services and to conduct day to day health care operations.

Notice of Privacy Practice. This document represents our Notice of Privacy Practices. You have received two copies of this document. Please read in it its entirety, sign and return one copy to our office.

Right to Inspect & Obtain Medical Records. Our office has established policies and procedures relation to patients obtaining copies of their medical records. Appropriate charges will apply, as well as the patient's signed consent for us to provide such documentation. If parties other than the patient request these records, a signed release/consent is required.

Right to Amend/Append Medical Records. State and Federal law provide guidelines in which patients may amend or append their medical records. All documentation in the patient's medical records will be done in accordance with all applicable laws.

Right to Authorize Certain Non-Treatment Disclosures. Patients have the right to request that disclosure of their condition and/or treatment is limited as provided by law. Restrictions on disclosures to family members (including parents), employer(s), marketing or advertising affiliates, research organizations, etc. can be made directly with the physician. Verbal/Written approval to disclose protected health information will be obtained prior to disclosure.

Right to Request Restrictions on Use of Medical Records. You have the right to request, in writing, specific restrictions on the use of your medical records and protected health information. Upon receipt of such request(s), we will restrict disclosure as provided by applicable law.

Right to Request Alternative Channels of Communication. If you wish for us to communicate with you via alternative channels of communication, please make these requests in writing, including the method through which you wish us to contact you. It is our policy to send mail to the address provided on our patient demographics forms, to contact you by telephone at either your home, cellular, or work telephone numbers, and to leave non-descriptive messages via answering machine. If you prefer an alternate channel of communication, again, please put your specific requests in writing. If you prefer to have your results sent to you via e-mail, please write your e-mail address below:

Persons to whom you consent for protected health information to be disclosed to:

I have read this document and understand it, I consent to the use and disclosure of my personal health information for purposes of treatment, payment and healthcare operations. I have received a copy of the Notice of Privacy Practices from this office.

1. All material presented to our patients is written in English. If you have any difficulty understanding these written materials and require a translation of the documents, please let us know.
(Todo el material presentado a nuestros pacientes está escrito en inglés. Si tiene alguna dificultad para comprender estos materiales escritos y necesita una traducción de los documentos, háganoslo saber.)

2. We request a 72 hour cancellation notice on "PROCEDURES" (EXCLUDING WEEKENDS). Failure to call to cancel or reschedule within this timeframe will result in a $300.00 administrative fee that is not billable to insurance. This includes instances when the office must cancel your procedure due to your failure to abide by the pre-operative instructions (ie. prep, stopping medications, etc.). This administrative fee must be paid in full prior to scheduling any other appointment whether it be an office visit or procedure.

3. We request a 24 hour cancellation notice on "OFFICE APPOINTMENTS". Failure to call to cancel or reschedule within this timeframe will result in a $50.00 administrative fee that is not billable to insurance. This administrative fee must be paid in full prior to scheduling any other appointment whether it be an office visit or procedure.

4. You must request medical records in writing.

5. All Copays, Deductible, and Coinsurance amounts are due at the time the service is rendered. Past due balances must also be collected at the time of each office visit or procedure.

6. A $35.00 charge for ALL RETURNED CHECKS will be incurred in accordance with Florida Law.

7. In providing health care services, it is unlikely but possible that conflicts or disputes may arise. In order to avoid time consuming and expensive legal costs in resolving these disputes, we have decided to use a mandatory arbitration program administered by the fully independent and highly professional American Arbitration Association. Please review the attached Arbitration Agreement for Health Care Services and sign the agreement if it meets with your approval.

**By signing below, I acknowledge that I have read and understand the above policies.

Gastroenterology Specialist, INC
3355 Burns Rd, Suite 306
Palm Beach Gardens, FI 33410
PH: 561-630-8775

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.

A photocopy of this Assignment/Authorization and/or Agreement shall be considered as effective and valid as the original.
Each time you visit our physicians or receive treatment from us, a record of your visit is made. This record may contain your
symptoms, examination and test results, diagnoses, treatment a plan for future care or treatment and billing-related information.
This notice applies to all of the records of your care generated by your physician.

 

We are required by law to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to that protected health information, and to notify any affected individuals following a breach of any unsecured protected health information. We will abide by the terms of the notice currently in effect.

For Treatment: We may use protected health information about you to provide you with treatment or services. We may disclose protected health information about you to doctors, nurses, or other personnel who are involved in taking care of you. For example, we may need to communicate with your primary care doctor to plan your treatment and follow-up care.

For Payment: We may use and disclose protected health information about your treatment and services to bill and collect payment from you, your insurance company, or a third-party payer. For example, we may need to give your insurance company information about your diagnosis so that it will pay us or reimburse you for the treatment.

For Healthcare Operations: We may use or disclose, as needed, your protected health information in order to run our practice. For example, members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve.

 

We may also use and disclose protected health information:

• To business associates we have contracted with to perform an agreed-upon service
• To remind you that you have an appointment for medical care
• To assess your satisfaction with our services
• To inform you about possible treatment alternatives
• To inform you about health-related benefits or services
• To conduct case management or care coordination activities
• To contact you as part of our fundraising efforts, if any, though you will have the right to opt out of such communications
• To inform funeral directors consistent with applicable law
• For population-based activities relating to improving health or reducing healthcare costs
• For conducting training programs or reviewing competence of healthcare professionals

We may release protected health information about you to a friend or family member who is involved in your medical care or who helps pay for your care.

Research: We may disclose information to researchers when an institutional review board has approved the disclosure based on adequate safeguards
to ensure the privacy of your health information and as otherwise allowed by law.

As Required by Law, we may also disclose health information to the following types of entities, including but not limited to:

• The U.S. Food and Drug Administration
• Public health or legal authorities charged with preventing or controlling disease, injury, disability, or other threat to health or safety
• Correctional institutions (if you are in custody of a correctional institution or a law enforcement officer)
• Workers' compensation agents
• Organ and tissue donation organizations
• Military command authorities
• Health oversight agencies
• Funeral directors, coroners, and medical examiners
• National security and intelligence agencies
• Protective services for the president and others
• Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to
  a valid subpoena or court order

Uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses and disclosures not described in this notice or required by law will be made only with your separate written permission. If you give us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any lime. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the right to:

• Inspect and copy protected health information. You may request access to your records by contacting us. You may also ask that we send your health information directly to another person based on your signed written instructions. We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed in some situations. Another licensed healthcare professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. We reserve the right to charge you a reasonable fee to cover the cost of providing you with a copy of your records.
• Request an amendment. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information by making a request in writing that explains the reason for the requested amendment. You have the right to request an amendment for as long as the information is kept for or by us. We may deny your request for an amendment if this occurs, you will be notified of the reason for the denial.
• Request an accounting of disclosures. This is a list of certain disclosures we make of your protected health information for purposes other than treatment, payment, healthcare operations, or certain other permitted purposes.
• Request restrictions or limitations on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request, except as described below. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If you ask us not to disclose your health information to your health plan, we will agree as long as (i) the disclosure would be for the purpose of payment or health care operations and is not otherwise required by law and (ii) the information only relates to items or services that someone other than your health plan has paid for in full.
• Request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at work or by U.S. mail. We will grant requests for confidential communications at alternative locations and/or via alternate means only if the request is submitted in writing and the written request includes a mailing address where you will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response.
• A paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

We reserve the right to change this notice; the revised notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and will include the new effective date. Copies of any revised notices will be available on our website and will be provided to you upon your next visit to our facility after the effective date.

I acknowledge and agree that I am responsible for all charges for services provided to me which are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent no coverage exists under my Plan, I acknowledge that I am responsible for all charges for services provided and agree to pay all charges not covered by my Plan.

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer 561-630-8775, or by contacting the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

I, the undersigned, assign to the provider/entity referenced above ("Provider"), my rights and benefits in any medical insurance plan, health benefit plan, or other source of payment for healthcare services (each a 'Plan") in connection with medical services provided by Provider, its employees and agents. I understand that this document is a direct assignment of my rights and benefits. under my Plan. I authorize my insurance company to pay Provider directly for the professional or medical expense benefits payable to me. If my current policy prohibits direct payment to Provider, I instruct my insurance company to make out the check to me and mail it directly to the address of lockbox referenced above for the professional or medical expense benefits payable to me under my Plan as payment towards the total charges for the services rendered. In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Provider are owed to Provider and I agree to remit those funds directly to the Provider.