Patient Consent and Notice of Privacy Practice
Notice of Privacy Practice Form
I hereby give my consent for Prospect Pediatrics, PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The notice of privacy practices provided by Prospect Pediatrics, PA describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Prospect Pediatrics, PA reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Director Office Operations Prospect Pediatrics, PA
With this consent, Prospect Pediatrics, PA may call my home or other alternative location and leave message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Prospect Pediatrics, PA may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Prospect Pediatrics, PA may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patients statements. I have the right to request that Prospect Pediatrics, PA restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Prospect Pediatrics, PA to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Prospect Pediatrics, PA may decline to provide treatment to me.
Prospect Pediatrics, PA PA Financial Policy
ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE WE DO NOT BILL SECONDARY INSURANCE COMPANIES
Prospect Pediatrics, PA is committed to providing you with the best possible care and will be pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important for our professional relationship. Please ask if you have any questions regarding our fees, financial policy or your responsibility. We are doing everything possible to hold down the cost of medical care. You can help a great deal by eliminating the need for us to bill you. The following is a summary of our payment policy.
It is your responsibility to have your most current insurance details with you. You will be asked for your card and applicable co-payments. If your insurance has changed, please obtain the expiration date of your old policy and the effective date of the new coverage, prior to your appointment or visit to the office. If this information is not provided or your insurance is inactive on the day of service, you will be expected to pay before being seen.
Prospect Pediatrics, PA accepts cash, personal check, VISA, MasterCard. There is a service charge for returned checks. Patients with an outstanding balance 30 days overdue must make arrangements for payments prior to scheduling appointments or Prospect Pediatrics, PA will decline to see the patient. The outstanding balance must be paid within 30 days of receiving statement from Prospect Pediatrics, PA. Prospect Pediatrics, PA will decline to see patients with outstanding balances.
INSURANCES
If we have not received payment from your insurance company within 45 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges.
COMMERCIAL INSURANCE
We bill participating insurance companies as a courtesy to you. If you are covered by a commercial insurance carrier that we accept, we will file a claim to your carrier. You must pay any Co-pay, Coinsurance or any deductible at the time service is rendered. If you are a member of any other insurance carrier that we do not accept, you are expected to pay in full at the time service is rendered, and we will provide you with the necessary forms to file a claim with your insurance for reimbursement. The practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. I do not have to sign this authorization in order to receive treatment from Prospect Pediatrics, PA. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written evocation must be submitted to the Privacy Officer at 163 Belleville Avenue Belleville, NJ 07109
MEDICAID
We bill participating insurance companies as a courtesy to you. We accept Medicaid assignments. Prospect Pediatrics, PA does adhere to the New Jersey Medicaid Agreement and Title 42 code of the federal regulation 447.20 and Civil Rights Act of 1964.
SELF PAY
Full payment is due at the time service is rendered. We accept cash, credit cards and debit cards. We try to make our fees reasonable and affordable if you are without insurance at the time of your visit. If you become eligible for insurance coverage after you have already paid for an appointment we will not be able to file your insurance. However, we will be happy to provide you with the necessary forms to file a claim with your insurance for reimbursement.
REFUNDS
Overpayments will be refunded upon written request to the responsible party within 30 days.
WALK IN PATIENTS
if you are not a patient of Prospect Pediatrics, PA and want to be seen, e.g. vacationer or out of town guest, you must pay in full for the visit. However, you will be given at the time of service receipt to submit a claim to your insurance company.
MISSED APPOINTMENTS / LATE CANCELLATIONS
Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late - to cancel appointments. Excessive abuse of scheduled appointments may result in discharge from the practice.
More than 3 no-shows for physical appointments will result in termination from Prospect Pediatrics, PA. Prospect Pediatrics, PA reserves the right to terminate patients who do not follow medical advice given by the doctor and do not show up for follow up appointments.
AGREEMENT
In consideration of the services rendered to me by my physician, I agree to pay all charges incurred as a result of such services. If all or part of my charges are payable by a third party reimburse, I understand that it is my responsibility to contact such third party payer and to arrange for payment. I agree that should the amount for insurance benefit be insufficient to cover the expenses, I will be responsible for payment of the difference. I will be responsible for the entire amount due (excluding disallowed amounts per a managed care contract) for services rendered if the expense is not covered under my policy. I understand that Prospect Pediatrics, PA will not become involved in disputes between me and my insurance company regarding deductibles, co-payments, covered charges and/or usual and customary charges other than to supply factual information as necessary.
All fees are due and payable upon billing. The undersigned will pay all costs and expenses including collection fees and attorney fees incurred or paid by Prospect Pediatrics, PA in the collection of this obligation by suit or otherwise.
This agreement shall remain in effect until revoked by me in writing. I also permit Prospect Pediatrics, PA to use photocopies of these agreements in place of the originals on file at Prospect Pediatrics, PA. Please let us know if you have any questions or concerns.