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. If you have any questions about this Notice please contact: our Privacy Contact who is Nancy Allison or current Practice Manager. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by [accessing our website www.nwaobgyn.com, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Based Upon Your Written Consent You will be asked by your physician to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, your physician will use or disclose your protected health information as described in this Section 1. Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you. We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materials not be sent to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you. Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgement, that you intend to consent to use or disclosure under the circumstances. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq. 2. Your Rights Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by contacting our Privacy Contact. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 3. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Contact, Nancy Allison or the current Practice Manager at (479) 582-9268 or www.nwaobgyn.com for further information about the complaint process. This notice was published and becomes effective on January 6, 2003. Back To Top ______________________________________________________
Obstetrics & Gynecology Our physicians specialize in Obstetrics and Gynecology, which enables them to care for the female patient from the time before her first menstrual cycle, through the childbearing years and then through menopause. This includes but is not limited to: performing Pap smears, infertility, providing prenatal care, delivery of your baby, management of contraceptive choices, tubal ligation, laparoscopic surgery, hysterectomy, hormone replacement therapy and urinary incontinence surgery. The physicians will also help with preventive medicine by recommending mammography and screening colonoscopy. Appointments Most appointments are scheduled in advance. The time allotted is dependent upon the nature of the visit: whether it is an initial, routine or follow-up exam or if there will be an ultrasound or other procedure performed. If you must reschedule your appointment, we ask that you notify our office 24 hours in advance. We reserve the right to charge patients who fail to show for appointments without notifying our office in advance. We want to be able to schedule all patients that need care as soon as possible. Telephone Calls Please call during regular office hours for office appointments, prescription refills, and insurance or medical problems. If you need to speak with a nurse or the physician, you will be asked to leave your name and number, and they will return your call. If it is after hours, call the office number to obtain the after hours physician contact instructions. Payment & Fees Payment for your care is due at the time provided. The only exception to this policy is if we are contracted with your health insurance plan (see insurance below). The fee for an office visit will range from $60.00 to $200.00. If you have a pap smear, lab work or other services, there will be additional charges. Cash, Check, MasterCard, Visa and Discover are acceptable payment methods. Insurance You are required to present your insurance identification card at the time of your appointment. We will file a claim for your services if we are contracted with your health insurance plan. Please, verify in advance that the physician you have chosen to see is contracted with your plan. Any co-payment, co-insurance, and/or deductible is due at the time of service. Please be prepared to pay this amount. A co-payment is normally a fixed dollar amount per office visit, identified on your insurance card. Co-insurance is the percentage of the bill that is the patient’s responsibility. A deductible is a fixed dollar amount that must be paid before the insurance will begin to pay. Again, if you do not have your current insurance identification card or other acceptable proof of insurance, your visit will be considered private pay and you will be responsible for full payment at the time of service. Referral If your insurance plan requires a referral, it is your responsibility to request the referral from your primary care physician to be sent to our office. Failure to obtain a referral when required can result in reduced benefits or non-payment by your insurance company, making you responsible for payment of the visit. Wellness Benefits A wellness, annual or preventative exam is defined as a visit without complaints. If you have insurance, our office will file your claim to reflect this. Should your visit include a problem that requires treatment, you may also be charged an additional office visit for the problem addressed, along with another office visit for the preventative visit. Please be familiar with your insurance benefits before seeing the doctor. Our office will not change a diagnosis after the claim has been filed. If you have any questions, please feel free to talk with our insurance department or your physician. OB Patients At the time of your pre-natal nurse visit, you will meet with a Patient Representative who will review our OB fees and prepare a payment plan based on the maternity benefits provided by your plan. You are required to present your insurance identification card at the time of this visit. If you do not have insurance, or your plan does not include maternity benefits, a deposit will be required. In all cases, payment of patient portion is due in full by the beginning of the 7th month of pregnancy. Prescriptions If medication is prescribed at your appointment, you will be given a written prescription that can be filled at your local pharmacy. If you need a refill before your next appointment, please call the office, during regular business hours, two days in advance of needing the medication. This allows the doctor the time to review your chart and make a decision. If your refill request is not approved, you will be called and an appointment can be scheduled at that time to see the doctor. Prescriptions will not be re-filled after office hours or on week-ends. Back To Top ______________________________________________________ FINANCIAL POLICY PAYMENT & FEES Payment for your care is due at the time provided. The only exception to this policy is if we are contracted with your health insurance plan (see insurance below). The fee for an office visit will range from $60.00 to $200.00. If you have a pap smear, lab work or other services, there will be additional charges. Cash, Check, MasterCard, Visa and Discover are acceptable payment methods. INSURANCE You are required to present your insurance identification card at the time of your appointment. We will file a claim for your services if we are contracted with your health insurance plan. Please, verify in advance that the physician you have chosen to see is contracted with your plan. Any co-payment, co-insurance, and/or deductible is due at the time of service. Please be prepared to pay this amount. A co-payment is normally a fixed dollar amount per office visit, identified on your insurance card. Co-insurance is the percentage of the bill that is the patient’s responsibility. A deductible is a fixed dollar amount that must be paid before the insurance will begin to pay. Again, if you do not have your current insurance identification card or other acceptable proof of insurance, your visit will be considered private pay and you will be responsible for full payment at the time of service. It is, at all times, your responsibility to follow up on all requests from your insurance company regarding claims and to question any unpaid insurance claims. If you do not receive an explanation of benefits from your insurance within 60 days of your visit, please call them. After insurance has processed your claim, you will be billed for any remaining balance or non-covered services. This amount is due upon receiving your statement. Your insurance makes the final determination regarding payment at the time the claim is processed. WELLNESS BENEFITS A wellness, annual or preventative exam is defined as a visit without complaints. If you have insurance, our office will file your claim to reflect this. Should your visit include a problem that requires treatment, you may also be charged an additional office visit for the problem addressed, along with the charge for the preventative visit. Please be familiar with your insurance benefits before seeing the doctor. Our office will not change a diagnosis after the claim has been filed. If you have any questions, please feel free to talk with our insurance department or your physician. REFERRAL If your insurance plan requires a referral, it is your responsibility to request the referral from your primary care physician to be sent to our office. Failure to obtain a referral when required can result in reduced benefits or non-payment by your insurance company, making you responsible for payment of the visit. OB PATIENTS At the time of your pre-natal nurse visit, you will meet with a Patient Representative who will review our OB fees and prepare a payment plan based on the maternity benefits provided by your plan. You are required to present your insurance identification card at the time of this visit. If you do not have insurance, or your plan does not include maternity benefits, a deposit will be required. In all cases, payment of the patient portion is due in full by the beginning of the 7th month of pregnancy. I, the undersigned, have read and understand the financial policy as described above and agree to pay for any and all medical services including, portions not covered or denied by my insurance. Failure to pay in a timely manner will result in my account being turned over to an outside collection agency. __________________________________________________________ Patient Signature & Date MEDICAID WAIVER Medicaid will only pay for services that they deem "necessary" and that are filed in a timely manner. If for any reason Medicaid does not pay your charges due to your lack of benefit knowledge or the correct procedures are not followed, you as the patient are responsible for all charges. Your signature is required to insure that you are aware of your responsibilities. This is an agreement that you are willing to pay any charges that Medicaid denies. If for any reason you do not present to the office with your Medicaid card before your scheduled appointment with the physician you will be asked to reschedule or you will be considered self-pay for the duration of care. __________________________________________________________ Patient Signature & Date __________________________________________________________ Witness Signature & Date CHAMPUS WAIVER Champus will only pay for services that it determines to be "reasonable and necessary" under 32CFR of the Congressional Federal Register Part 199, dated June 1, 1993-Final Rule. This law further states that even Champus non-providers can only charge 115% of the Champus allowable, unless the patient signs a waiver stating that they are aware of the 115% limit and the patient agrees to pay the additional amount. Your signature is required each time that you are seen in our office. This will assure that you as the patient are completely aware that your are responsible for any amount that Champus does not pay, even if our amount exceeds 115% of the Champus allowable. _________________________________________________________ Patient Signature & Date _________________________________________________________ Witness Signature & Date Back To Top | 
