Primary Care Provider

I hereby agree to the following conditions/statements: 

PRIVACY NOTICE

 This Privacy 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.   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 share a single patient record with other practices that use our electronic medical record system (Acumen 2.0), in compliance with state and federal laws, and in accordance with Acumen 2.0 rules which are available at https://acumenmd.com/wp-content/uploads/2020/01/Acumen-Data-Sharing-Rules-ofthe-Road.pdf. Our medical group’s ability to access your records for treatment and related purposes is critical to maintaining continuity of patient care and improving the quality and efficiency of health care, all of which benefit the individual patient. Each practice is responsible for obtaining your consent or authorization required by state and federal laws applicable to that practice before accessing, using or disclosing information in your record.

We will not use or share your information other than as described here unless you tell us that we can in writing.  If you tell us we can, you may change your mind at any time, and you will be required to notify us in writing.

We can change the terms of this notice and the changes will apply to all the information we have about you. The new notice will be available at the time of any changes.

Our Uses and Disclosures

1. Treatment: We can use your health information and share it with other professionals who are treating you.  For example, your information may be disclosed to your primary care physician or to another specialist who referred you to WNA for treatment.
2. Healthcare Operations:  '(/ e can use and share your health information to run our practice, improve your care, and contact you when necessary.  For example, your information may be used and disclosed by WNA to engage in case management, coordinate your care, schedule your appointments and inform you of your lab results.  We may contact you to give you information about treatment alternatives or other health benefits and services that may be of interest to you.
3. Payment:  We can use and share your health information to bill and get payment from health plans or other entities.  For example, your information may be used and disclosed to submit claims to your insurer and/ or to obtain payment for services provided.

B.  Your Choices:  Uses and Disclosures with Your Verbal Consent

 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, please tell us what you want us to do.

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.
• Share information in a disaster relief situation
• Include your information in a hospital directory
• Contact you for fundraising efforts- We may contact you for fundraising, but you can tell us not to contact you again for fundraising.

Please note: 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:

• For marketing
• For the sale of your information
• For most sharing of psychotherapy notes

 C.  Other Uses and Disclosures without your consent.

 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.

Public Health and Safety

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

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 are 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 worker’s 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.

 D.  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.

1.    Get a copy of your medical record. You can ask to see or get a copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request.  We will charge a reasonable, cost-based fee.

2.    Ask us to correct your medical records. You can ask us to correct health information about you if you think it is incorrect or incomplete.   We may say “no” to your request, but we’ll tell you why in writing within 60 days.

3.    Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will say “yes” to all reasonable requests. Please note that email is not always secure.  We will do our best to protect your health information, but we do not guarantee privacy through email.

4.    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” if it would affect your care. 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.

5.    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 yo1,1 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.

6.    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.

7.    Choose someone to act for you. If you have given someone 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 that a person has this authority and can act for you before we take action.  We will require an executed medical power of attorney form for our records.

8.    File a complaint. If you feel your rights have been violated, you can contact us at:

Barbara Rotter, Privacy Officer

Administration

Washington Nephrology Associates, LLP

1201 Seven Locks Rd, Suite 200,

Rockville, MD 20854

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 Ave, SW

Washington, DC 20201

1-877-696-6775

www.hhs.gov/ocr/privacy/hipaa/complaints/

We will not retaliate against you for filing a complaint.

 

Release and Use of Health Information
  

PATIENT AUTHORIZATION WAIVER FOR DISCLOSURE OF INFORMATION TO ANY WASHINGTON NEPHROLOGY ASSOCIATES ADMINISTRATIVE STAFF EMPLOYEE TO DISCUSS ANY MEDICAL CONDITION (S) WITH FAMILY MEMBERS OR DESIGNATED PERSON (S)

 I am a patient of Washington Nephrology Associates, L.L.P. (WNA) and hereby authorize the support staff. I.e. secretaries, medical assistants, nurses, etc. to discuss my medical condition with the members of my family listed in the Registration Form. 

The patient or the patient’s legal representative must read the following statements:

A.  I understand that the provision of health care and the payment of health care will not be affected if this form is not signed.

B.  I understand that I may revoke this authorization at any time by notifying Washington Nephrology Associates in writing, but it will not affect any actions taken by Washington Nephrology Associates prior to receiving the revocation.

Please initial and sign on Registration Form

 

Patient Consent to the Use and Disclosure of Information

 Washington Nephrology Associates, L.L.P. (“WNA”) obtains and maintains health information relating to my past, present or future physical or mental condition, and provision of health care or payment for healthcare referred to as “Protected Health Information.”  This Protected Health Information may be used or disclosed by WNA for purposes of treatment, payment or health care operations, including, but not limited to:

• Planning for my care and treatment
• Calling me with appointment reminders and lab results
• Submitting a claim to my insurer or health plan
• Assessing the quality of care provided to me

WNA’S Notice of Privacy Practices contains a more complete description of how my Protected Health Information may be used or disclosed and how I can obtain access to this information.  I understand WNA reserves the right to change its Notice and practices and I can request a copy of its current Notice.

I understand that I have the right to request restrictions as to how my Protected Health Information may be used or disclosed by WNA.  WNA is not required to agree to my request but if WNA does agree, the requested restrictions will be binding on WNA.

I further understand that, at any time, I may revoke this consent in writing, except to the extent that WNA has already taken action in reliance on it.

 

Email Policy
 

Washington Nephrology Associates (WNA) will use reasonable means to protect the privacy of your health information sent by email.  However, because of the risks outlined below WNA cannot guarantee that email communications will be confidential.   Additionally, WNA will not be liable if you or anyone else inappropriately uses your email.  WNA will not be liable for improper disclosure of your health information that is not caused by WNA’s intentional misconduct.

Email risks and your responsibility
 

At the discretion of the WNA, its staff, physicians and agents (WNA) and upon your agreement to the terms outlined within this consent form, you may use email to communicate with WNA.  These emails may contain your personal health information.   If you decide to use email to communicate with WNA, you should be aware of the following risks and/or your responsibilities:

1.     As the Internet is not secure or private, unauthorized people may be able to intercept, read and possibly modify email you send or are sent by WNA.

2.     You must protect your email account, password and computer against access by unauthorized people.

3.     Since email can be used to spread viruses, some which cause email messages to be sent to people who you do not intend to send email messages to, you should install and maintain virus protection software on your computer.

4.     Since emails can be copied, printed and forwarded by people to whom you send emails, you should be careful regarding whom you send emails.

5.     As your employer may claim ownership of, or the right to access, the email account issued to you by our email, you should avoid using an employer-issued email account to communicate with WNA.

 

Conditions for the use of the email
 

By consenting to the use of email with WNA, you agree that:

 WNA may forward emails as appropriate for diagnosis, treatment, reimbursement, and other related reasons.  As such, WNA staff members, other than the recipient, may have access to emails that you send.  Such access will only be to such persons who have a right to access your email to provide services to you.   Otherwise, WNA will not, otherwise, forward emails to independent third parties without your prior written consent, except as authorized or required by law.

1.    Although WNA will try to read and respond promptly to your emails, WNA staff may not read your email immediately.   Therefore, you should not use email to communicate with WNA if there is an emergency or where you require an answer in a short period of time.

2.     If your email requires or asks for a response, and you have not received a response within a reasonable time period, it is your responsibility to follow up directly with WNA.

3.    You should carefully consider the risk of using email for the communication of sensitive medical

4.   Information, such as, but not limited to, information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

5.    You should carefully word your email messages, so the information provided clearly, yet briefly,

6.    Describes the information you intend to convey.  You should avoid writing long “chatty” emails.

7.    You are responsible for correcting any unclear or incorrect information.

8.    WNA reserves the right to save your email and include your email or information contained within your email in your medical record.

9.   It is the patient’s responsibility to follow up and/or schedule an appointment if warranted or recommended by WNA.

10.                Emails may not be the only form of communication that WNA will use to communicate with you.

11.                Additionally, WNA may decide that it is not in your best interest to continue to communicate with you by email. In such a case, WNA will notify you that it no longer intends to communicate with you by email.

 

Medical Release Authorization and
Insurance Assignment

 

I hereby authorize Washington Nephrology Associates to apply for benefits on my behalf for covered
services rendered. I request payment from my insurance company to be made to the above-named
provider. I understand and agree that, regarding my insurance status, I am ultimately responsible for
the balance on my account for any professional services rendered.
I request that payment of authorized Medicare benefits be made to Washington Nephrology
Associates for any services rendered. I authorize any holder of medical information about me to be
released to the Health Care Financing Administration and its agents, any information needed to
determine these benefits or the benefits payable for related services.
I certify that the information I have reported regarding my insurance coverage is correct and further
authorize the release of any necessary information, including medical information, to my insurance
company in order to determine insurance benefits to which I may be entitled. I may revoke this
authorization at any time in writing.
I authorize Washington Nephrology to release and/or send medical information regarding my case
to other consulting and/or referring physicians.

Missed/Canceled Appointment Policy
 

We want to thank you for choosing us as your health care provider.  In order to give you and all our patients, the best possible care, we request that you review our policy regarding missed appointments.  A missed appointment is when you fail to show up for an allotted appointment time, without a phone call or cancellation notice of at least 48-hour notice.  Please remember we reserved appointment times especially for you. Therefore, we request at least a 48-hour notice in order to cancel and reschedule your appointment.  This will allow us the opportunity to better serve our patients and ensure we can accommodate everyone by offering your canceled time to others.

 If you are unable to keep your scheduled appointment time, please call our office at least 48- hours in advance in order to avoid a missed appointment fee of $100 for a consultation visit or $60 for a follow-up visit. This charge is not covered by your insurance carrier.

Financial Responsibility Agreement
 

I understand that my insurance is a contract between me and the insurance carrier, and not between the insurance carrier and Washington Nephrology Associates and that I am still fully responsible for all fees.  Washington Nephrology Associates, LLP (WNA) will apply for benefits on my behalf for covered services. Payment will be made from the patient's insurance to WNA. The patient is ultimately responsible for the balances in the accounts. including all co-payments, deductibles and non-covered charges by health insurance.

Should timely payments of this account not be made, I authorize Washington Nephrology Associates to retain the services of an attorney and/or collection agency to assist with the collection of the outstanding balance.  Any expenses incurred by such action shall become an additional liability for the patient.