Becoming a New Patient at Watertown Family Practice

Thank you for your interest in becoming a patient at Watertown Family Practice. Before we schedule your first appointment, we ask all new patients to complete our New Patient Enrollment Packet. This helps us create an accurate chart, verify insurance, collect required privacy acknowledgments, set up your patient portal account, and make sure you understand our office policies before your first visit.

Watertown Family Practice HIPAA Privacy Policy

Purpose: To explain how we collect, use, disclose, and protect patients' protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Scope: This policy applies to all providers, staff, contractors, and agents of Watertown Family Practice who create, receive, maintain, or transmit PHI.

Policy:

1. Use and Disclosure: PHI will be used and disclosed only for treatment, payment, and healthcare operations, or as otherwise permitted or required by law. We will limit disclosures to the minimum necessary to accomplish the intended purpose.

2. Patient Rights: Patients have the right to access their PHI, request amendments, obtain an accounting of disclosures, request restrictions on certain uses and disclosures, and request confidential communications.

3. Safeguards: Watertown Family Practice implements administrative, physical, and technical safeguards to protect PHI against unauthorized access, use, or disclosure. Access to PHI is granted only to staff with a legitimate need.

4. Incidental Disclosures: Reasonable safeguards will be used to minimize incidental disclosures of PHI. Such disclosures will be limited and occur only when necessary.

5. Breach Notification: In the event of an unauthorized use or disclosure that constitutes a breach of unsecured PHI, Watertown Family Practice will follow required breach notification procedures, including notifying affected individuals and, when applicable, the Department of Health and Human Services and the media.

6. Workforce Training: All workforce members will receive HIPAA training and periodic updates on privacy and security requirements.

7. Business Associates: We will enter into written agreements with business associates who create, receive, maintain, or transmit PHI on our behalf, requiring them to safeguard PHI and comply with HIPAA.

8. Complaints: Patients may file complaints about our privacy practices with Watertown Family Practice’s Privacy Officer or with the Department of Health and Human Services. No retaliation will be taken against individuals who file complaints. Contact: For questions about this policy or to exercise HIPAA rights, contact Watertown Family Practice’s Privacy Officer at the practice contact information.

Patient Agreement & Acknowledgement PATIENT AGREEMENT & ACKNOWLEDGEMENT Watertown Family Practice Associates, S.C. (WFPA) has established a patient agreement to ensure you receive the best possible care. Please read through the following statements carefully. Your signature is requested on the final page acknowledging agreement. We are pleased to serve you as a patient and look forward to providing continuation of care.

1. PATIENT PORTAL: All new patients are required to register for the Patient Portal. The portal serves as an online communication system between the provider and patient. Through the portal patients can send messages directly to their provider, schedule and view upcoming appointments, view medications, labs, test results, check account balance(s), and much more.

2. MEDICATION POLICY: Patients who have been prescribed medications by a practice provider are required to attend an annual appointment to re-fill medications. Due to Wisconsin and The United States Drug Enforcement Administration (DEA) requirements WFPA will not prescribe any chronic narcotics or opioids to new patients. These medications need to be managed by a Pain Management Clinic and WFPA will not prescribe an interim supply of these medications.

3. PATIENT WELLNESS: WFPA requires patients to follow age recommended wellness requirements. Examples include Annual Wellness Visits, routine colon, breast, and cervical cancer screenings, age-appropriate vaccinations, and other preventive screenings and measures.

4. CO-PAYMENT amounts are required at the time of your visit. We accept cash, check, or credit card. If you are unable to pay the co-payment at check-in, your appointment will need be re-scheduled.

5. INSURANCE: WFPA participates with most insurance plans. We will file claims for all insurance plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. As a courtesy to our patients, we will verify your insurance coverage, however, our verification is not a guarantee of benefits payable by your insurance. To bill your insurance and to meet filing guidelines we do ask for a copy of your insurance card and a photo ID. If our providers are not listed in your plan’s network, you may be responsible for partial or full payment.

6. SELF-PAY/UNINSURED: Patients who do not have insurance or have insurance that cannot be verified by Watertown Family Practice will be considered Self-Pay. Self-Pay patients are required to make deposit in the amount of $250 via cash or credit card upon check-in on date of service. A 25% discount will be applied to total visit cost if paid in full before leaving.

7. RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible to Watertown Family Practice Associates, S.C. for charges not covered by the assignment of insurance benefits and all non-covered charges.

8. AUTHORIZATION & ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize Watertown Family Practice Associates, S.C. to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to Watertown Family Practice Associates, S.C. all payments otherwise payable to me for services provided.

9. BILLING AND COLLECTION FEES: Watertown Family Practice Associates, S.C. will submit a claim for payment to your insurance company. In the event your insurance carrier/company denies the services provided, you will be responsible for the payment in full. We appreciate prompt payment in full for any outstanding balance.

10. PAYMENT PLANS: All unpaid balances 30 days or older will be considered for patient payment plan agreements. All balances must be paid within the 3-, 4-, 6-, or 12-month timeframes as designated on Patient Payment Plan Agreement. All unpaid balances 90 days or older will be turned over to a collection agency, and patient will be discharged from the clinic.

Thank you for completing our New Patient Enrollment Packet. Click submit to securely send it to our staff at Watertown Family Practice. Once your electronic chart and patient portal account have been created, we will reach out to you to schedule an appointment.  Please allow up to 5 business days for us to get things ready and reach out to you.

We look forward to meeting you soon!