This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purpose of treatment, payment and health care operations.
This notice also describes how medical information about you may be used and disclosed and how you can get access to this information.
I am committed to protecting the privacy of my patients’ personal and health information. I may use or disclose your protected health information for purposes of treatment, payment or practice operations only with your written consent. For example, I may contact another physician to coordinate your care, submit a claim to an insurer, or look at your file to perform an internal quality monitoring. I agree to obtain your written authorization for any other use or disclosure. You may revoke your consent or authorization at any time in writing. Otherwise, this agreement will expire and need to be renewed after one year from the date of signing.
Consent regarding medical information:
With my consent Harvey A. Lerchin, M.D. 1) may use or disclose protected health information (PHI) about me in order to carry out treatment, payment and healthcare operations (TPO), but will not release information to other third parties without my expressed written approval of that disclosure; 2) may call my home or other designated location and leave a message or 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 results; 3) may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminders and patient account statements.
I have been offered the opportunity to review Harvey A. Lerchin’s Notice of Privacy Practices for a more complete description of such uses and disclosures.
- Payments: Your payment in full is appreciated at time of services. However, monthly statement can be arranged, in which case payment is due 15 days after your receipt of the billing statement. Beyond that date, a surcharge of 1.0 per cent per month will apply to the outstanding account balance. Statements for the purpose of submission to your health insurer will gladly be provided, upon your request.
- HMO/PPO Contracted Services: Your co-payment for services rendered is due at the time of service. The patient or responsible party remains responsible for payment of my charges if the insurer denies payment after proper billing has been submitted and processed.
- Failed Appointments: Fees for failed scheduled appointments are the responsibility of the patient, not the insurer. Full fee is charged for failed appointments.
- Cancellations: If less than 48 hours notice (including Sundays and Holidays) is not given to my office, payment for the full charge for the scheduled procedure rests with the patient or the responsible party. [If there is a compelling reason for the late cancellation, a reduced charge of 50 per cent of the usual fee may be negotiated].
- Extraordinary Services: Requests for extra reporting, conferences or indicated collateral services will be charged at an established per hour rate. Testimony and deposition services are charged at a premium rate that will be specifically negotiated if that need arises.
- Telephone or E-mail Consultations: Prorated charges will be levied for excessive or extended telephone consultations or special services, such as therapeutic treatment requests of insurers, complex or extraordinary prescription orders or arrangement of inpatient, PES or IOP care.
- Prescription Refills: Requests for prescription refills by mail, pick-up or telephone will honored, although 48 hour notice is needed for this service. There will be a nominal charge for this service.
By signing this form I am consenting to Harvey A. Lerchin, M.D’s use and disclosure of my PHI and TPO and to the policies listed above. I may revoke my consent, in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent or has already performed services covered by the above policies. If I do not sign this consent Harvey A. Lerchin, M.D. may decline to provide treatment to me.
