HIPAA Disclosure and Privacy Practices
Your Patient Health Information (PHI) will be used in this office and you have rights concerning those records. In addition to how your PHI will be used, office policies regarding payment and collections, and consent to treat are listed below. By signing this form, you agree to all stipulations of our policies listed.
- Patient understands and agrees to allow MedPlex, Inc to use their PHI for the purposes of treatment, payment, health care operations and coordination of care.
- The patient has the right to examine and obtain a copy of his/her own health records at any time and request further restrictions on the use of their PHI. Our office in not obligated to agree to those restrictions.
- A patient’s written consent need only be obtained one time for all subsequent care given to the patient in the office.
- The patient may provide a written request to revoke consent but would apply to any care given after the request has been presented.
- For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known to assure that your records are not readily available to those who do not need them for treatment.
- Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
- If the patient refuses to sign this consent for the purpose of treatment, payment or health care operations, the medical physician has the right to refuse care.
Authorizations, Assignments of benefits, and consent to treat to MedPlex, Inc physician’s hereafter referred to as the “Office”.
- I understand that Michael Chandler, MD is a PMD (Preferred Medical Doctors) with Blue Cross Blue Shield, and that BCBS will not be filed within the office of MedPlex Inc. for physician consultation, evaluation and treatment. I understand I will be responsible for all office fees at the time of service. You are free to see a provider at a different clinic who accepts insurance and that physician may submit claims to BCBS for your care.
- I authorize, assign and direct my insurance carrier to pay directly to said office such sums as may be due and owing the Office of services rendered to me, now and hereafter, which are payable under my insurance contractor contractual agreement.
- I understand that my insurance will be billed for my urine drug screen confirmations. I will be responsible for the amount not covered by my insurance.
- I understand that email and/or text messages may be used to remind me of appointments. You may opt out of this by simply notifying the front desk in writing. A form will be available for you to fill out if you do not wish to be reminded by email and/or text messages.
- I agree that in the event I receive checks, drafts or other payments subject to this agreement, I agree to act as fiduciary agent to the Office. The Office agrees to apply any proceeds to the patient’s debt for services rendered.
- I fully understand and agree insurance policies are an arrangement between the insurance carrier and myself. I may be responsible for expenses not paid by insurance. I understand and agree to pay the customary charges of the Office and agree that if my health insurance does not pay for my treatment in full, I will be responsible for the remaining balance. I understand and agree that I will pay for my treatment in full; I will be responsible for any remaining balance. I understand and agree that I may be charged for missed appointments.
- I agree the Office has the right to call my home, place of employment, and cell phone regarding my appointment times and other issues, requests and notifications.
- I have read the above consent. I have also had an opportunity to ask questions about course of treatment for my present condition and future condition for which I seek treatment. A photocopy of this form shall be as valid as the original.
NOTICE OF PRIVACY PRACTICES
This notice describes how medical/protected health information about you may be used, disclosed, and how you can get access to this information. Please review it carefully.
As a patient, you have the following rights:
- The right to inspect a copy of your information
- The right to request corrections to your information
- The right to request your information be restricted
- The right to request confidential communication
- The right to a report of information disclosures
- The right to a paper copy of this notice
If you have any questions about this Notice, the name and phone number of our contact person is listed on this page.
I have read and understand how my patient health information will be used, as well as the Privacy Practice of MedPlex, Inc. I further authorize MedPlex Inc to use my private health information for the purposes stated in this agreement in the manner stated in the agreement. Also, I hereby acknowledge that I have received a copy of this practice’s Privacy Practices and HIPAA disclosure. I understand that if I have questions or complaints regarding my rights that I may contact MedPlex Inc at the number listed above. I further understand that the practice will offer me updates to these practices should it be amended, modified, or changed in any way.