FINANCIAL RESPONSIBILITY
High West Medical will collect full payment for services and products after each visit. I understand that insurance will not be billed for appointments, and I am financially responsible for all charges.
HIPAA INFORMATION and CONSENT FORM
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, text message, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or healthcare provider.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
I, the undersigned, have been issued the HIPPA NOTICE OF PRIVACY PRACTICES. I fully understand that High West Medical is required by law to maintain the privacy of my medical and health information. I acknowledge that the practice will use and disclose my health information for purposes of treating me, obtaining payment for services referred to me and conducting health care operations.
CANCELLATION/NO-SHOW POLICY
We would like to thank you for being a patient in our office. We value all of our patients and strive to provide the best care possible in the most comfortable setting. Please understand that when we schedule your appointment, we are reserving time for your particular needs. We kindly ask that if you must change your appointment, please give us a 24 hour notice. This courtesy makes it possible to give your reserved time to another patient who would like it. If you are unable to keep an appointment we ask that you cancel at least 24 hours in advance. If this is not possible, please call us as soon as you can so that another patient can be given your appointment time. We understand that occasional missed appointments can occur for a variety of reasons. When you miss an appointment without canceling, someone else who could have been seen in your place is delayed unnecessarily. If you are more than 10 minutes late, you may be asked to reschedule.
A “no show/ late cancellation” is defined as missing an appointment without canceling at least 24 hours before scheduled time. There will be a $50 charge for missed, late-canceled, or non-cancelled appointments.
Repeated missed appointments may result in needing to put down a nonrefundable deposit.
