THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU: The following categories describe different ways which we use and disclose medical information. For each category of uses or disclosures, we will elaborate on the meaning and provide more specific examples, if you request. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

FOR PAYMENT: We may use and disclose medical information about you so that the treatment and services you receive at the Practice may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may disclose your record to an insurance company so that we can get paid for treating you.

FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the Practice or the hospital. For example, we may disclose medical information about you to people outside the Practice who may be involved in your medical care, such as family members, clergy, or other persons that are part of your care.

FOR HEALTH CARE OPERATIONS: We may use and disclose medical information about you for health care operations. These usages and disclosures are necessary to run the Practice and ensure that all our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students and other Practice personnel for review and learning purposes. For example, we may review your record to assist our quality improvement efforts.

WHO WILL FOLLOW THIS NOTICE: This notice describes our Practice’s policies and procedures and that of any health care professional authorized to enter information into your medical chart, any member of a volunteer group that may be allowed to help you, as well as all employees, staff and other Practice personnel.

POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION: We create a record of the care and services you receive at the Practice. We need this record in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Practice, whether made by Practice personnel or by your personal doctor. The law requires us to: make sure that medical information that identifies you is kept private; give you this notice or our legal duties and privacy Practices with respect to medical information about you; and to follow the terms of the notice that is currently in effect. Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law; for health-related benefits and services; to individuals involved in your care or payment for your care; research; to avert a serious threat to health or safety; and for treatment alternatives. Other uses and disclosures of your personal information could include disclosure to or for: coroners, medical examiners and funeral directors; health oversight activities; inmates; law enforcement; lawsuits and disputes; military and veterans; national security and intelligence activities; organ and tissue donation; protective services for the President and others; public health risks; and worker’s compensation.

NOTICE OF INDIVIDUAL RIGHTS … You have the following rights regarding medical information we maintain about you:

• RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer.
• RIGHT TO AMEND: If you feel that any medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by, or for, the Practice. To request an amendment, you request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request. We may deny your request for an amendment.
• 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 treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. WE ARE NOT REQUIRED 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. To request restrictions, you must make your request in writing to the Privacy Officer.
• RIGHT TO INSPECT AND COPY: We have the right to inspect and copy medical information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstance.
• 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. You must make your request in writing and you must specify how or where you wish to be contacted.
• RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right to a paper copy of this notice. You may ask us to give you a copy of this summary or the detailed notice at any time.

CHANGES TO THIS NOTICE: We reserve the right to change this notice.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our Practice, please contact our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION: Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. I also give permission to view my external prescription history via the RxHub service. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies and pharmacy benefit managers may be viewable, and it may include prescriptions from the past several years.

You will be required to sign a paper copy of this Policy which may also be accessed from the "forms" tab or by clicking here.

Thank you for choosing Heart of Georgia Rheumatology as your healthcare provider. For clarity and to avoid any confusion, the following is a comprehensive statement of our Financial Policy. We require you to read and sign it prior to any treatment.

All co-payments and deductibles are due at the time of service. Full payment is due at the time of service for all non-covered services. Our contract with your insurance company requires us to collect these from you. With the rising cost of medical care, paying at the time of service is essential in keeping these costs at a minimum. Payment in full is required without proof of insurance coverage, or if you are self-pay with no insurance coverage.

It is your responsibility to check with your insurance company prior to your appointment for verification of benefits such as preventive services, lab and x-ray procedures, etc. Many insurance plans now require you to go to specific labs, x-ray facilities, pharmacies, etc.

It is your responsibility to give us accurate and updated insurance information at each visit. Failure to do so may result in you being responsible for a balance that your insurance company may have otherwise paid. Many managed care insurance plans have strict guidelines regarding timely filing which makes accurate information a necessity. If you are covered under more than one insurance plan, please remember to give us information on all plans at the time of service.

Retroactive insurance coverage: We will only file the insurance that is presented at the time of your visit. We will not file retroactive insurance that you have applied for and received coverage after services have been rendered for that date of service. If you are self-pay at the time of service, we will not refile any insurance that you have obtained that will retroactively cover that date of service. You will be responsible for the full charges and no refund will be given.

It is important for you to respond to your insurance company when any information is requested from you. Often, they will send questionnaires regarding other coverage and will not process your claim until you respond. Some insurance companies require this with your first claim each calendar year. Do not make the mistake of thinking you have already given them this information and it is not necessary to respond. When your insurance company notifies us they have requested information from you, the balance then becomes your responsibility and remains your responsibility until the claim is paid.

We understand unforeseen circumstances such as uncovered services and unplanned emergencies. In these situations, when you incur a balance, we require monthly payments with the expectation of paying the balance in full within 3 to 4 months. If this it not possible, please set up payment arrangements with our office.

If monthly payments are not received regularly, your account will automatically move into our collection process. We are willing to work with you on your balance, but communication with our billing staff is essential. If you have questions regarding your bill or wish to set up payment arrangements, contact our billing office. If your account has to be turned over to our collection agency for collection, this could result in your termination as a patient due to noncompliance with our financial policy. If you receive a bill that you feel is not your responsibility, it is important for you to communicate with our billing office.

Never ignore a bill simply because you feel it is not your obligation or you think your insurance company should pay it. You cannot assume your insurance company will cover any balance once we have transferred the responsibility of that balance to you. We only transfer responsibility to you after we have received a response from your insurance company.

It is important for you to read the explanation of benefits (EOB’s) sent to you from your insurance company. This will explain why certain charges are not covered and the amount that is your responsibility. If you have any questions regarding the coverage of your claim, you should contact your insurance company. If you have questions regarding your bill or wish to set up payment arrangements, please contact our billing office.

Please be aware, that if you have X-rays done in our office, you will receive a statement from the radiologist who will read your X-rays. Some lab tests may require the results to be sent to an outside lab for processing. If this occurs, you will receive a statement from that facility. If you have any questions regarding these issues, please ask to speak to our office manager.

AUTHORIZATION FOR RELEASE OF INFORMATION AND PAYMENT OF BENEFITS

I hereby authorize the release of any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS confidential information, necessary to process insurance claims or any medical information that is required for any healthcare related utilization review or quality assurance activities.

I hereby assign and authorize payment to Heart of Georgia Rheumatology of all medical benefits to which I am entitled to under any insurance policy or policies, under any self-insurance program, or under any other benefit plan.

I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility for all medical fees and charges incurred by me or anyone on my behalf and I hereby accept responsibility, including, but not limited to payment of those fees and charges not directly reimbursed to Heart of Georgia Rheumatology by any insurance policy, self-insurance plan or other benefit plan.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

You will be required to sign a paper copy of this Policy which may also be accessed from the "forms" tab or by clicking here.