AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
I hereby give my permission to PedPost Urgent Care to release the following information to my primary doctor; My complete medical records (incl. all lab reports and radiology reports)
Lab test result, Radiology reports/exams, My name and comments, including quotes, made by me regarding my care and treatment at PedPost. Please indicate other places, entities or providers we should send copies of the information above: (include name, organization, telephone number, fax number and mailing address).
NOTE: Should you authorize us to release your name and comments regarding your care you are authorizing us to provide that information to any media sources.
The above information is being released for the purpose of: (Unrestricted and unlimited purpose if left blank). Expiration Date of Authorization: This authorization is effective through // unless revoked or terminated earlier by the patient or the patient’s personal representative. Right to Terminate or Revoke Authorization: You may revoke or terminate this authorization by submitting a written revocation to PedPost Urgent Care. You should contact the Privacy Official to terminate this authorization. Potential for Re-disclosure: I understand my information may be mailed, faxed or picked-up in person. The person or organization sent or transporting the disclosed information under this authorization may disclose information again. It may not be possible to ensure your right to the protection of the privacy of this information once PedPost releases/discloses it to another party. Rights of the Individual: You may inspect or copy information used or disclosed under this authorization. You may refuse to sign this authorization. Effect of Refusing Authorization: If you refuse to sign this authorization, PedPost will not deny you any treatment except treatment that you have requested for the purpose of disclosure to other. I am a patient/parent or an authorized legal representative of patient and I have read, understand, will abide by and agree to Pedpost Urgents Care's Authorization of Release.
We are happy that you selected PedPost Urgent Care Center for your healthcare needs and look forward to providing you with excellent service in care. To help you understand your payment responsibilities in relation to your medical care, we would like to briefly outline our financial policy. We accept most forms of insurances with the exception of Medicaid and Medicare. We will bill your insurance carrier as a courtesy to you. Patients are expected to provide identification and if insured, a current insurance card(s) at time of service. Patients are financially responsible for all services provided and are expected to pay for services at time of service, including any past due balance from a prior date of service. If the patient is a minor child, the parent or other adult accompanying the child will be financially responsible regardless of legal guardianship. Patients, parents of patients or legal guardians and non-legal accompanying adults are responsible for the following (when applicable): Annual deductibles and co-insurances, All applicable co-pays of the allowed charge, Any non-covered services
Any covered service ordered by the physician which does not meet medical insurance’s medical necessity and for which the beneficiary signed an Advanced Beneficiary Notice (ABN).
Secondary Insurances: The Practice will bill secondary insurances in accordance with its contractual agreement with your medical insurance or workers compensation insurances policies.
Medicaid: WE DO NOT ACCEPT MEDICAID. Medicaid will not be considered a secondary insurance under any circumstances and as such, Medicaid recipients with or without a secondary or tertiary medical insurance will be billed as self-pay. Services provided to Medicaid Patients with a commercial or other non-Medicaid secondary insurance will be billed to the commercial insurance as the primary insurance and to the patient as self-pay for any outstanding non-covered balances unpaid by their commercial insurance. In the event patient has a tertiary insurance under this scenario, the tertiary insurance will be billed as a secondary insurance but the patient, its legal guardian, parents or non-legal accompanying adults will be billed for any unpaid outstanding balance.
HMOs and PPOs, Commercial Insurance Plans: Patients are responsible for payment of the co-pay, coinsurance and/or deductible, or non-covered amounts at the time of service as well as for any charges for which the patient failed to secure prior authorization, if authorization is necessary. Insurance is filed as a courtesy and benefits are authorized to be paid directly to the Practice. Patients are responsible for the balance in full if not paid by the insurance within 30 days. If the patient is not prepared to pay the co-pay or deductible, a member of the clinical staff will determine if it is medically necessary for the patient to see the physician. If the patient’s condition allows, the appointment will be rescheduled.
Self-Pay: Patients are responsible for payment in full at the time of services for all services rendered.
Worker’s Compensation: Employer authorization must be obtained before treatment is rendered or the patient will be responsible for payment in full at the time of services for all services rendered. Once authorized, patients are not responsible for any charges unless the workers compensation case is dismissed or denied.
Personal Injury/Motor Vehicle Accidents and Other Third Party Liability: The patient is responsible for the balance in full at the time of service. We will submit the bill to your insurance carrier. Any settlement you receive from your insurance company or other third party will be handled by you, your insurance company, and/or your attorney.
Out of State Insurance: If the patient presents with an out of state HMO/PPO insurance card, we will need to verify the patient’s benefits for out-of-state or out-of-network benefits. The patient may be required to make payment in full or pay any co-pay, co-insurance or deductible.
Refunds: In accordance with your insurance contract, we do not refund insurance reimbursements to you for any charges applicable to the cost of providing you healthcare where your insurance paid for the services rendered. In the event you are disputing charges, paid by your insurance carrier to our office, it is your responsibility to contact them directly. Your insurance carrier will notify you as to what actions they are taking and if you paid for services that was covered by insurance, your insurance carrier will refund you the portion that is owed to you.
Refunds for online booking: Appointments cancelled on day (within 24 hours) of appointment are subject to "no refunds" if paid for already.
I am a patient/parent or an authorized legal representative of patient and I have read, understand, will abide by and agree to Pedpost Urgents Care's Financial Policy.
NOTICE OF PRIVACY PRACTICES
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.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We are committed to protecting medical information about you. This Notice describes our privacy practices and that of all its employees and staff. This Notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:
Give you this Notice of our legal duties and privacy practices with respect to medical information about you;
Make sure that medical information that identifies you is kept private; and
Follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways we use and disclose medical information. For each category we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment. We may use and disclose medical information about you to provide you with medical treatment or services. For example, a specialist we may refer you to may need to know about a treatment you received at our office in order to coordinate other treatments you are receiving.
Payment. We may use and disclose medical information about you so that the treatment and services you receive at our office may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at our office so your health plan will pay us or reimburse you for the services.
Health Care Operations. We may use and disclose medical information about you for our office operations. These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our office.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a close personal friend or family member who is involved in your medical care or payment for your care, so long as you have not objected and it is reasonable for us to infer that such disclosure is in your best interest.
Special Purposes When Permitted or Required by Law. We may disclose medical information about you as for special purposes when permitted or required by law, including the following:
To avert a serious threat to health or safety against you, the public or another person.
For public health and administrative oversight activities such as disease control, abuse or neglect reporting, health and vital statistics, audits, investigations, and licensure reviews.
For organ and tissue donation and transplant to facilitate organ or tissue donation and transplant.
For research purposes limited information may be disclosed as permitted by law.
To workers’ compensation or similar programs for the payment benefits for work-related injuries.
To coroners, medical examiners and funeral directors to identify a deceased person, determine cause of death, or to carry out duties.
To comply with court orders, judicial proceedings, or other legal processes related to law enforcement, custody of inmates, legal and administrative actions, and criminal activity.
For U.S. military and veteran reporting regarding members and veterans of the armed forces of U.S. or foreign military.
For national security and intelligence activities such as protective services for the President and other authorized persons.
State and Other Federal Laws. We will comply with all applicable State and Federal laws. For example, under State law, there are more limits on the disclosure of HIV and AIDS information. We will continue to abide by all applicable state and federal laws.
Other Uses of Medical Information Require an Authorization. Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us an authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by the written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provide to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have many rights with regard to your medical information. If you wish to exercise any of these rights, you must submit your request in writing, unless otherwise noted.
Your Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. We may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
Your Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to add a statement. You must provide a reason that supports your request for an amendment.
Your Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of certain disclosures we made of medical information about you. Your request must state a time period. We may limit the time period to 6 years and to disclosures made on or after April 14, 2003. The first list you request within a 12-month period is free. For additional lists, we may charge you for the costs of providing the list.
Your Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you. For any services for which you paid out-of-pocket in full, we will honor any request you make to restrict information about those services from your health plan, provided that such release is not necessary for your treatment. In all other circumstances, we are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Your Right to 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 can ask that we only contact you at work or by mail. If we maintain medical information about you in electronic format, you also have the right to obtain a copy of such information in electronic format and to direct us to transmit such information directly to an entity or person clearly, conspicuously, and specifically designated by you. We will not ask you the reason for your request. You may make this request in writing or verbally.
Right to Paper Copy of this Notice. Your have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us. You may also file a complaint directly with the Secretary of the Department of Health and Human Services. You will not be penalized in any way for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our offices and make copies available upon request.
I am a patient/parent or an authorized legal representative of patient and I have read, understand, will abide by and agree to Pedpost Urgents Care's Notice of Privacy Practices.
Patient Rights and Responsibilities
We believe that patients who understand and participate in their treatment achieve better results. Please take a moment and familiarize yourself with your rights and responsibilities as a patient.
You have the right to:
Know the risks, benefits and alternatives to proposed treatments or procedures
Choose the physicians or other clinicians who will be providing care or treatment, as well as have information about them
Receive information in easy to understand terms that will allow for an informed consent
Privacy regarding medical care
Participate in the plan of care, including your treatment plan, notifying your family or physician of admission and discharge planning
Refuse care, treatment, and services in accordance with law and regulation
Be informed about the outcomes of care, treatment, and services
Receive information and communication in an understandable manner and preferred language including provision of interpreter and translation services
Receive information and communication to accommodate vision, speech, hearing, or cognitive impairments.
Formulate advanced directives and have staff and practitioners comply with those directives
Reasonable responses to reasonable requests of service
Leave the medical center against the advice of the physician
Examine and receive an explanation of the bill for services regardless of the source of payment
Select providers of goods and services after discharge
Receive a Notice of Privacy Practices
Request privacy protection
Access protected health information in a reasonable time frame
Amend protected health information
Request an accounting of disclosures of protected health information
Be free from any forms of restraint or seclusion as a means of convenience, discipline, coercion, or retaliation
The least restrictive restraint or seclusion should be used only when necessary to ensure patient safety
Care regardless of your race, color, religion, sex, national origin, age, ability to pay or disability and any other legally prohibited reasons.
Receive care in a safe and dignified environment, free from all forms of abuse, neglect, harassment and/or exploitation
Protection and respect of your rights if you are participating in a human research clinical trial.
Have a support person during care provided it does not interfere with the rights of other patients or the care process.
Consent to receive the visitors who you designate, including but not limited to a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend. You may withdraw your consent to receive any visitor at any time. To the extent this hospital places limitations or restrictions on visitation, you have the right to set any preference of order or priority for your visitors to satisfy those limitations or restrictions. This hospital does not and will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. This hospital will ensure that the visitors chosen by you will be able to enjoy full and equal visitation privileges, consistent with your preferences.
You have the responsibility to:
Provide accurate and complete information concerning your present medical condition, past illnesses or hospitalization and any other matters concerning your health
Tell your caregivers if you do not completely understand your plan of care
Follow the caregivers’ instructions
Follow all medical center policies and procedures while being considerate of the rights of other patients, medical center employees and medical center properties
You also have the right to:
Lodge a concern with state and regulatory agencies, whether you have used the hospital’s grievance process or not. If you have concerns regarding the quality of your care, coverage decisions, or want to appeal a premature discharge, you may contact the following regulatory agencies via phone, fax or mail:
Georgia Department of Community Health
Healthcare Facility Regulation Division
Healthcare Facility Regulation Complaint Intake Unit:
(404) 657-5726, (404) 657-5728 or (800) 878-6442.
2 Peachtree Street, NW, Suite 3100
Atlanta, GA 30303
Georgia Medical Care Foundation
Quality Improvement Organization
1455 Lincoln Parkway, Suite 800
Atlanta, Georgia 30346
Regarding problem resolution, you have the right to:
Express your concerns about patient care and safety to hospital personnel and/or management. If your concerns and questions can not be resolved at this level, contact The Joint Commission at 1 (800) 994-6610, by Fax at (630) 792-5636, by e-mail at , or by mail at: Office of Quality Monitoring • The Joint Commission One Renaissance Boulevard • Oakbrook Terrace, IL 60181
Patient has received, reviewed, read and understands his or her rights and responsibilities as expressed above.
PRIVACY & BILLING PROCEDURES
These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates of service. I understand I may revoke this authorization by informing PedPost Urgent Care in writing, but if I do revoke this authorization, it will not affect anything prior to the date the revocation is received by PedPost Urgent Care. PedPost Urgent Care will use my home phone number and primary address supplied during registration to contact me regarding my treatment; including lab results, x-rays, and medical records. I will ensure this information is up to date at every visit. I consent to be treated by PedPost Urgent Care as a patient. If I am not the patient being treated, I am authorized to consent to treatment and billing for the patient identified the patient the online appointment is made for. I authorize PedPost Urgent Care to bill my medical insurance, Employers or Workers Compensation Insurance for the care I receive and to release any information the insurance carrier requires to process this bill. I authorize payment of medical benefits to PedPost Urgent Care, or to outside labs as described below, for all services performed and billed by PedPost Urgent Care. I understand that I am responsible for all charges for the treatment I receive at PedPost Urgent Care. I understand that PedPost Urgent Care providers may utilize the Prescription Monitoring Program service at no additional charge to me.
As a courtesy, PedPost Urgent Care will bill my medical insurance. If I do not provide complete and accurate insurance information to PedPost Urgent Care, I understand PedPost Urgent Care may not receive payment from my medical or workers compensation insurance company or employer and I will be entirely responsible for my bill. Even after my employer, medical or workers compensation insurance company pays PedPost’s bill, I may owe PedPost payment for services not covered by my insurance and I agree to pay these promptly to PedPost. I understand that PedPost may send lab specimens to an outside laboratory. I authorize any lab performing services for me to bill my employer, medical or workers compensation insurance directly or indirectly for their services. I understand that my employer, medical or workers compensation insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that PedPost is not responsible for payment to outside labs for tests provided to me.
To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, PedPost may choose not to bill insurance and may decline credit/debit cards and checks as a form of payment. I understand that if I fail to pay PedPost for services provided to me, the balance owed may be sent to collection and I may incur collection fees of up to 25% in addition to the amount owed for services/treatment rendered. I understand that I may contact PedPost to work out payment arrangements that may prevent this additional cost.
I am a patient/parent or an authorized legal representative of patient and I have read, understand, will abide by and agree to Pedpost Urgents Care's Privacy and Billing Procedures.