MAIN STREET MEDICAL CENTER

Subtitle

Policies and Consents

Contents

PRIVACY POLICY.. 2

ASSIGNMENT OF BENEFIT AGREEMENT. 12

PATIENT FINANCIAL RESPONSIBILITY STATEMENT. 13

PATIENT ACKNOWLEDGEMENT AND CONSENT TO ONLINE INTERACTION POLICIES. 20

DRUG HISTORY CONSET. 23

CONSENT FORM FOR ePRESCRIBE PROGRAM... 23



PRIVACY POLICY

Main Street Medical Center
Notice of Privacy Practices

This notice contains important information about our privacy practices which were revised pursuant to the Health Insurance Portability and Accountability Act of 1996 and related regulations. This notice describes how your Protected Health Information may be used and disclosed, and indicates how you get access to this information. Please review it carefully.

If you have any questions about this notice, please contact our Front Office Manager.

RedRiverClinic@gmail.com

OUR COMMITMENT TO YOUR PRIVACY

Summary

1. We are dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding the treatment and services we provide to you.

2. Your medical records are our property. However, we are required by law:

a. To maintain the confidentiality of your medical information;

b. To provide you with this notice of our legal duties and privacy practices concerning your medical information called Notice of Privacy Practices;

c. To follow the terms of our notice of privacy practices in effect at the time.

3. This notice provides you with the following important information:

a. How we may use and disclose your medical information;

b. Your privacy rights regarding your medical information; and

c. Our obligations concerning the use and disclosure of your medical information.

Changes to this Notice
The terms of this notice apply to all records containing your medical information that are created or retained by us. We reserve the right to revise, change or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any medical information that we may receive, create, or maintain in the future. You may request a copy of our most current notice during any visit to our practice.

HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe the different ways in which we may use and disclose your Protected Health Information. Please note that each particular use or disclosure is not necessarily listed below. However, the different ways we are permitted to use and disclose your medication information do fall within one of the listed categories.

Treatment
We may 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 may also disclose protected health information to their 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
We may use and disclose your medical information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your medical information to obtain payment from other third parties who may be responsible for such costs. Also, we may use your medical information to bill you directly for services and items under applicable law.

Health Care Operations
We may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our organization is well run. An example of the way in which we may use and disclose your information for our operations would be to evaluate the quality of care you received from us. We may also disclose your information to doctors, nurses and students for review and learning purposes. We maintain safeguards to protect your Protected Health Information against unauthorized access and uses. We may 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.

Appointment Reminders
Our organization may use and disclose your protected health information to remind you that you have any appointment.

Disclosure
We shall only disclose protected health information as permitted by law or with your permission. In addition, we shall make every effort to prevent unintentional disclosure although the regulations consider such disclosure legal. When necessary for your care or treatment, our operations and related activities, we use protected health information internally and may disclose such information to other healthcare providers (doctors, dentists, hospitals, nursing homes or other covered healthcare providers, insurers, third party administrators, payers, and others who may be financially responsible for payment for services and benefits you receive, vendors, consultants, government authorities and other surveying entities and their respective agents). These parties are required to keep your protected health information confidential, as provided by law. Some examples of what we do with the information we collect and the reasons:

1. Administration of health benefits policies or contracts which may involve claims payment and management; utilization review and
Management; medical necessity review; coordination of care and benefits;

2. Quality assessment and improvement activities, such as peer review and credentialing of participating providers, program development and accreditation;

3. Performance measurement and outcomes assessment and health claims analysis;
4. Data and Information systems management; and
5. Performing regulatory compliance/reporting, and public health activities; responding to requests for information from regulatory authorities, responding to government agency or court subpoenas as required by law, reporting suspected or actual fraud or other criminal activity; conducting litigation, arbitration and performing third-party liability, subrogation and related activities.

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 judgment, that you intend to consent to use or disclosure under the circumstances.

Treatment Alternatives/Health-Related
We may use and disclose your medical information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you.

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 will use or disclose medical information about you when required by applicable law.

Public Health Activities
Our organization may disclose your medical information for public health activities, including;

1. To prevent or control disease, injury or disability;

2. To maintain vital records, such as births and deaths;
3. To report child abuse or neglect;

4. To notify a person regarding potential exposure to a communicable disease;

5. To notify a person regarding a potential risk for spreading or contracting a disease or condition;

6. To report reactions to drugs or problems with products or devices;

7. To contact public health surveillance, investigation or intervention;

8. To notify individuals if a product or device they may be using has been recalled;

9. To notify appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient including domestic violence; however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; and
10. To notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Abuse, Neglect and Domestic Violence
We may disclose your medical information to a government authority if we believe you are a victim of abuse, neglect or domestic violence. If we make such a disclosure, we will inform you of it, unless we think informing you places you at risk of serious harm or if we were to inform your personal representative, is otherwise not in your best interest.

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 Activities
We may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs and compliance with civil rights laws.

Lawsuits and Similar Proceedings
We may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your medical information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement
We may release medical information if asked to do so by law enforcement officials:

1. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement per state law;

2. Concerning a death we believe might have resulted from criminal conduct;

3. Regarding criminal conduct at our practice.

4. In response to a warrant, summons, court order, subpoena or similar legal process;

5. To identify/locate a suspect, material witness, fugitive or missing person; and

6. In an emergency, to report a crime (including the locating or victim(s) of the crime, or the description, identity or location of the perpetrator).

Coroners, Medical Examiners, and Funeral Directors
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release medical information about our patients to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation
We may use or disclose your medical information to organizations that handle organ and tissue procurement, banking or transplantation.

Serious Threats to Health or Safety
We may use or disclose your medical information when necessary to reduce or prevent a serious threat to your health and safety or another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Specialized Government Functions
We may disclose your medical information if you are a member of the U. S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your medical information to federal and/or state and/or local officials for intelligence and national security activities authorized by law. We also may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state or to conduct investigations.

Furthermore, we may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary:

1. For the institution to provide health care services to you;

2. For safety and security of the institution; and

3. To protect your health and safety or the health and safety of other individuals.

Workers’ Compensation or Disability Claims
We may release your medical information for your workers’ compensation and disability claims and similar program to appropriate agencies.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding the medical information that we maintain about you:

Requesting Restrictions
When requested in writing, you have the right to request a restriction in your medical information for treatment, payment or healthcare operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use and disclosure of your medical information you must make your request in writing to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You need not give a reason for your request.

Confidential Communications

You have the right to request that we communicate with you about your health and related issues in a particular manner, or at a certain location. For instance, you may ask that we contact you by mail, rather than by telephone, or at home rather than work. In order to request a type of confidential communication, you must make a written request to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.

Inspection and Copies
You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about you, including patient medical records and billing records. Please make all record requests through the secure messaging service on our website. Otherwise, you must submit your request in writing to the Privacy Officer in order to inspect/or obtain a copy of your medical information. In accordance with state law we may charge a fee. In accordance with law and our best judgement, we may deny your request to inspect and/or copy your medical information in certain limited circumstances; however, you may request a review of our denial.

Amendment
You may ask to amend your medical information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by our Practice. To request an amendment, your request must be made in writing to our Practice. You must provide us with a reason that supports your request for amendment. We may deny your request if you fail to submit your request and the reason supporting your request in writing. Also, we may deny your request if the amendment would violate any law or statute or if you ask us to amend information that is:

1. Accurate and complete;

2. Was not created by us; or

3. If the individual who created the information is no longer an employee of our Practice.

Accounting of Disclosures
An accounting of disclosures is a list of certain disclosures we have made of your medical information that you did not specifically authorize. You have the right to request a copy of our accounting of disclosures for your medical information. Your request must be made in writing to the Privacy Officer. All requests for an accounting of disclosures must state a time period that may be no longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge. A charge for subsequent requests in the same 12-month period will be imposed in accordance with state law.

Right to a Paper Copy of This Notice
You have the right to receive a paper copy of our Notice of Privacy Practices. You may print a copy of this notice from our website. To obtain a copy of this notice, ask any member of our staff or contact the Privacy Officer.

Right to File a Complaint
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 Officer of your complaint. We will not retaliate against you for filing a complaint.

Right to Provide an Authorization for other Used and Disclosures
We shall make a good faith effort to obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing by sending a written, signed and dated request to the Privacy Officer. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your permission. Please note that we are required to retain records of your care.

*Signature found on patient registration.

ASSIGNMENT OF BENEFIT AGREEMENT


I hereby authorize my insurance company, including Medicare if I am a Medicare Beneficiary, to make payments to Main Street Medical Center for medical or surgical services or items rendered to me or my dependent by Main Street Medical Center. Should my insurance carrier deny Main Street Medical Center payment, I understand that I am financially responsible for the charges. I authorize Main Street Medical Center to release any and all of my records to my insurer, or any other third-party payer, legally responsible for the payment of medical expenses. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance and health information.

*Signature found on patient registration.

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

Thank you for choosing Main Street Medical Center (also referred herein as MSMC) to serve you and your health care needs. The medical services you seek imply an obligation on your part to ensure payment in full is made for services received. This Patient Financial Responsibility Statement will assist you in understanding your financial responsibility. Feel free to ask questions. If someone else (parent, spouse, ect) is financially responsible for your expenses or carries your insurance, please share this Statement of Financial Responsibility with them, as it explains our practices regarding insurance billing, co-payments, and patient billing. By your acknowledgement of the Statement and / or by receipt of medical services from Main Street Medical Center of Red River, NM, you agree:

  1. You acknowledge and agree to all Financial Policies of Main Street Medical Center, including the policies available online at our website. Questions about these policies may be addressed to the front office staff. These policies may be changed periodically without prior notice.
  2. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by your insurance carrier or our Financial Policies, which are not otherwise covered by supplemental insurance.
  3. You are responsible for knowing your insurance policy. For example, you will be responsible for any charges if any of the following apply:
    1. Your health plan requires prior authorization or referral by a primary care practitioner (PCP)before receiving services at MSMC, and you have not obtained such an authorization or referral;
    2. You receive services in excess of such authorization or referral;
    3. Your health plan determines that the services you received at MSMC are not medically necessary and/or not covered by your insurance plan;
    4. Your health plan coverage has lapsed or expired at the time you receive services at MSMC;
    5. You have chosen not to use your health plan cover.
  4. If you are not familiar with your plan coverage, we recommend you contact your carrier or plan provider directly.
  5. You will be required to follow all registration procedures, which may include updating or verifying personal information, presenting verification of current insurance, and paying any co-pays or other patient responsibility amount at each visit. Your card or other insurance verification must be on file for your insurance to be billed. If we do not have your card on file, or are unable to verify your eligibility for benefits, you will be considered a self-pay patient. As a self-pay patient, our fee is expected to be paid in full at the time of service. If the insurance card or other necessary information is furnished after the visit, we may file a claim with your insurance; and if paid in full by your insurance, you will be reimbursed. If you are not prepared to make your co-pay or other patient responsibility amount, your visit may be rescheduled by MSMC office management.
  6. We may verify your insurance benefits or submit your claims to your insurance carrier as a courtesy to you. You agree o facilitate payment of claims by contacting your insurance carrier when necessary. Without waiving any obligation to pay, you assign to MSMC and its practitioner or associates, for application onto your bill for services, all of your rights and claims for the medical benefits to which you, or your dependents are entitled, under any federal or state healthcare plan (including, but not limited to Medicare and / or Medicaid), insurance policy, any managed care arrangements or other similar third-party payor arrangement that covers health care costs and for which payment may be available to cover the cost of the services provided to you. You authorize MSMC and its associated practitioner, staff and / or hospitals to release patient information acquired in the course of your examination and/or treatment including but not limited to any and all medical records, notes, test results, x-ray reports, MRI reports or other documents related to your treatment (including an itemization of any charges and payments on your account) that is deemed necessary to process this claim to the necessary insurance companies, their party payors, and/or other practitioners or healthcare entities as they require to participate in your care. It is important to notify us as soon as possible of any changes related to your insurance coverage. Failing to do so may result in unpaid claims, and you will be responsible for the balance of the claim. Main Street Medical Center does not accept responsibility for incorrect information given by you or your insurance carrier regarding your insurance benefits or benefit plans.
  7. If insurance does not remit timely payment on your claim, you will be responsible for payment of the charges within the terms set for in this Financial Statement. Timely payment is defined as eighty-nine (89) days or less. Once your insurance carrier processes your claim, we will bill you for any remaining patient responsibility deemed by your insurance carrier. If any payment is made directly to you for services billed by us, you agree to promptly submit the same payment to MSMC until your patient account is paid in full. If you make a payment that results in a surplus on your account, you authorized MSMC to apply the overpayment to any other account for which you are financially responsible, including your account, a member of your family’s or dependent’s account, or on any account for which you are a financially responsible part, and any remaining balance will be returned to the payor.
  8. You will be mailed a billing statement that contains the total cost of your service(s) or procedure(s) that were incurred during your visit(s). You may generally expect this billing statement within 20-25 days after your insurance company has responded to a submitted claim. You must notify us of any errors or objections to the billing statement within 20 days or they will be deemed accurate, and the fees and expenses shall be deemed reasonable and necessary for the services incurred. If there is a problem with your account, it is your responsibility to contact the Office Manger to address the problem or to discuss a workable solution.
  9. We accept payment by check, cash, money order, debit cards or credit cards (Visa, MasterCard, American Express or Discover).
    1. Payment by Check. If payment is made by check and it is returned or declined for any reason, your account will be charged a surcharge of $37.50 or up to the applicable state maximum legal limits, whichever is lower, in addition to any costs assessed or charged by any depository institution. When you pay by check you also authorize MSMC, if your check is dishonored or returned for any reason, to electronically debit your account for the amount of the check plus a processing fee of up to the state maximum legal limits (plus any applicable sales tax). PLEASE NOTE: The above language authorizes an electronic debit to your account for the amount of the check plus the state-allowed recovery fee. In accordance with the rules of the National Automated Clearing House Association, this authorization is to remain in effect until MSMC has received written notice of termination in such time and in such manner to afford us a reasonable opportunity to act on it. This does not, however, mean that MSMC cannot collect a returned check fee by other methods.
    2. Payment by Credit Card/Credit Card on File. When you pay by credit card, you agree to keep the credit card information on file with MSMC, and that information current. You authorize MSMC to securely store your credit card information, and only charge it should you have an outstanding balance or any leftover balance from a processed claim in the future. The storage system used is fully compliant to the highest level of credit card storage security regulations. Once stored, only the last five digits of your credit card are viewable by MSMC personnel. You understand that you are responsible for all charges for services that you receive from MSMC, and if the patient responsibility portion of your charges (including charges applied to your deductible and/or coinsurance) is not paid in full within thirty (30) days following receipt of the financial responsibility statement, then MSMC will bill your stored credit card for the outstanding balance due.

10. Managed Care (HMO, PPO, etc.). All managed care co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care physician, you are responsible for presenting this at your initial visit. If you request an office visit without a referral authorization, your insurance plan may deem this as “out of network” or “non-covered” treatment, and you will be responsible for a larger amount or all of the charges. You acknowledge that it is your responsibility to be aware of what services are covered, and you agree to pay for any service deemed to be non-covered or not authorized by the plan.

11. Medicare. Main Street Medical Center (MSMC) is a participating provider with the Medicare program and accepts as payment the Medicare allowable, patient deductible and/or 20% co-insurance. Medicare or secondary carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. You understand that you will be responsible for your annual deductible, the co-payment, and any non-covered services specified by Medicare. We may submit a claim to any supplemental plan as a courtesy to you, so long as you provide all necessary policy information.

12. Medicaid. If you are a Medicaid patient, you must present a valid eligibility card at the time of registration and prior to the time of service. We can only accept New Mexico Medicaid. Your eligibility status will be verified monthly. Without verification of coverage, you will be responsible for the entire balance of your account. As a courtesy to you, your account will be billed to Medicaid when we receive all necessary information. You are responsible for non-covered portions and spend down requirements associated with your individual coverage. If at any time you are not eligible for Medicaid coverage and wish to be seen, you will be treated as a self-pay patient and must make payment at the time of service.

13. Workers’ Compensation Cases. Charges for services incurred as a result of a verified work-related injury will be treated as workers’ compensation, and we will bill the workers’ compensation carrier as a courtesy. You must provide necessary information to bill the carrier. You are responsible for the completion of information with the employer and approval of the workers’ compensation claim. In case your workers’ compensation claim is denied, you will also provide us with your medical insurance information. If your claim is denied, we will bill your regular medical insurance carrier. When the claim is no longer pending and any portion of your claim is ultimately resolved against you by workers’ compensation and your medical insurance, you will be required to pay all amounts due within thirty (30) days.

14. Third-Party Liability Injuries. If you receive treatment because of a third-party liability injury (for example: motor vehicle accidents, premises liability, or other general liability claims against third parties), the balance for services rendered is considered due in full at the time of the service. Because MSMC does not protect charges incurred relating to or arising out of third party liability, we will not accept a delay in payment due to settlement disputes and/or litigation. We will not accept a letter of protection from an attorney as a guarantee of payment or assignment of third party insurance payments. Main Street Medical Center cannot act as administrator to resolve financial arrangements. We may agree to bill a third-party insurance company of an at-fault party involved in an accident as a courtesy to you. To bill your claim directly, you must provide us all necessary information to confirm coverage for these payments with the auto/third-party carrier. We will also collect information about your personal medical insurance in case the auto/third-party carrier denies your claim. Regardless of whether we submit your claim to third-party insurance, as the patient, you are ultimately responsible for payment.

15. Ancillary Services. You may receive ancillary medical services while a patient of MSMC such as: crutches, slings, braces, sterile surgical kits, non-injectable medications, ect. You may incur additional charges as a result of these ancillary services. You agree to pay all charges due with respect to such services upon receipt of items. If items are questionable and billed to your insurance and denied by your coverage, after benefits paid on your behalf by any third-party are credited to your account, you agree to pay for any ancillary services in full that remain outstanding.

16. Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of MSMC including but not limited to:

(i) charges for returned checks;

(ii) charges for a missed appointment without 24 hours advance notice at $65 (and will not be billed to your insurance company);

(iii) charges for extensive phone consultations (greater than 5 minutes) and/or after-hours phone calls requiring treatment, or prescriptions;

(iv) charges for copying and distribution of patient medical records;

(v) charges for extensive forms preparation or completion; or

(vi) any costs associated with collection of patient balances, all as allowed by law.

17. Non-Payment on Account. Should collection proceedings or other legal action become necessary to collect an overdue or delinquent account, you understand that MSMC has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. You are responsible for all costs of collection including, but not limited to:

(i) late fees and charges and administrative fees and interest due as a result of such delinquency;

(ii) all court costs and fees (but only to the extent allowed by law); and

(iii) a collection fee to be charged under separate agreement with a third-party collections agency, either as a flat fee or computed as a percentage of the total balance due up to the maximum allowed by applicable law, and to be added to the outstanding balance due and owing at the time of the referral to the third-party collection agency.

You acknowledge that any such interest assessed on the account will be a late fee as a result of default or delinquency on your account, and is not deemed interest as part of a credit transaction. If your account is referred to a collection agency, attorney, court, or the past due status is reported to a credit reporting agency, it may have an adverse effect on your credit history; and related portions of your account, including the fact that you received treatment at our offices, may become a matter of public record. Failure to comply with any of these policies may also result in a Credit Withdrawal of Care.

18. Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. A minor who is not accompanied by a parent/guardian will be denied any nonemergency treatment unless charges for the treatment have been pre-authorized. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of MSMC.

19. Authorization to Contact. You authorize MSMC personnel to communicate by mail, answering machine messages, and/or e-mail according to the information provided in your patient registration information. Main Street Medical Center (MSMC), or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact you for purposes related to your account, including debt collection. You authorize MSMC to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the contact.

20. Financially Responsible Party. If this or a separate Main Street Medical Center (MSMC) Financial Responsibility Statement is signed by another person, on your account, then that co-signature remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, you hereby guarantee the full and prompt payment to MSMC of all indebtedness of patient to MSMC, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by MSMC in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and shall remain in force and effect until any and all said Indebtedness shall be fully paid. There shall be no obligation on the part of MSMC at any time to first exhaust its remedies against Patient, any other party, or any other rights before enforcing the obligations of the financially responsible party.

*Signature found on patient registration.

PATIENT ACKNOWLEDGEMENT AND CONSENT TO ONLINE INTERACTION POLICIES

By providing your email address, you acknowledge the following:

I wish to use Internet-based communications, registration and other Internet-based modes of interaction to facilitate my receipt of health care from this practice.

Benefits and Risks:

  1. I understand that the benefits of Online Interaction include being able to take advantage of the expertise of a practitioner who may not be physically available to provide health care, and access to sources of information suggested by my own physician / practitioner.
  2. I understand that there are potential risks associated with receiving health care through Online Interaction, including for example, timeliness of the interactions and the inability of a practitioner to give me a complete physical examination. Consequently, there is a risk that a practitioner may not be able to determine the proper diagnosis and treatment based upon Online Interaction.
  3. I understand that the practice specifically reserves the right to withhold conclusions of diagnosis and/ or recommendations for treatment based upon information obtained via Online Interaction in the absence of an in-person encounter, and that I am not to interpret any comments of my practitioner(s) or the staff as a diagnosis or specific treatment instruction under those conditions, unless my personal physician/practitioner specifically indicates that I should.
  4. I understand that general information to which my practitioners(s) may refer me, or that which may be available on their Web sites, is not to be used for purposes of self-diagnosis or self-treatment, and to the extent that I do so I release my practitioner(s) and the practice and hold them harmless.

Confidentiality and Security of Information: 

  1. I understand that all state and federal rules and regulations governing confidentiality of my medical records and access to my Personally Identifiable Health Information (including my ability to obtain copies of my records) will apply to services provided through Online Interaction and to the electronic transmission and storage of my Personally Identifiable Health Information.
  2. I understand that my practitioners(s) and the practice will not give any images or information that identifies me and was obtained through Online Interaction to other entities without my consent unless permitted to do so under applicable laws or unless required to do so as part of a legal action. I have read and understand the privacy policy of the practice as published on its website.  
  3. I understand that when I conduct Online Interaction with the practices staff, I am subject to the privacy, confidentiality, and information security policies of those third parties and I have had the opportunity to review said policies.
  4. I understand that despite best efforts of all involved parties, there remains some amount of risk of inappropriate disclosure of my personal information, and I agree to hold the practice harmless for such disclosures when they occur as the result of acts or omissions of third parties. Use of Electronic Mail.
  5. I understand and agree that I am not to use the secure messaging service in emergency or other time-critical situations.
  6. I understand that the practice and its practitioner(s) discourage the use of standard e-mail for communicating about personal health issues, because standard e-mail is not a secure communications mechanism and does not provide structured forms of communication. Instead, the practice uses a secure, healthcare-oriented messaging service from Waiting Room Solutions, LLC.
  7. I understand that while I should not use regular e-mail to communicate to my practitioner and his/ her staff about personal health matters, standard e-mail may be used by the practice for purposes such as sending me notification of new messages that have been sent to my secure mailbox, or non- personal types of communications such as informing me of changes to office policies I understand and agree that I am to use appropriate language and tone in my messages and other Online Interaction, and in particular I am to avoid any language that abuses, mocks, belittles, or attacks the recipient or is in any way libelous to third parties. According to the Privacy Act of 1974 and court rulings, employers generally have the legal right to access any e- mail received or sent by a person at work. I understand generally that I should not communicate with the practice (including my practitioner(s) and staff, and including via standard e-mail) using computers or networks of my employer.
  8. I understand that online communications alone are not sufficient for proper medical care.
  9. I understand that my practitioner may refuse to continue online discussion of a condition when he or she believes an in-person encounter is appropriate.
  10. I understand that in no case should I expect my practitioner to deliver a conclusion of diagnosis, a recommendation for treatment, or a prognosis regarding a complaint or symptom for which I have not been seen in person, or regarding a condition for which I have not been seen in person within the previous 10 days.
  11. I understand that I am to keep copies of messages received from my practitioner.
  12. I understand that my practitioner will retain copies of our communications within my medical record.
  13. I understand that if my username and password is obtained by another individual, including an unauthorized family member, I am to notify the practice immediately and at the earliest opportunity should return to the practice or its website to establish a new username and password. Practitioner May Discontinue the Online Relationship at any time, and for any reason.
  14. I understand that my practitioner may discontinue his or her Online Interaction with me under any circumstance in which he or she believes that I have used Online Interaction in a manner that is inconsistent with his or her policies as stated herein.
  15. I understand that I will be notified of such termination of Online Interaction Ownership of Information.
  16. I understand that neither the practice nor my practitioner(s) make any claim of legal ownership of the electronic information that is exchanged via Online Interaction and stored by third- party providers of online services.
  17. I also understand that there are no current conclusions of law that would hold that the information is legally owned by me, by the practice, my practitioner(s), or the vendors of the online services used to create and store the information. However, I understand that I do have rights of access to the information, and rights of refusal to disclosures of the information.

Consent: 

I hereby consent to obtaining some aspects of my health care from the practice using Internet-based communications or other Internet-based modes of interaction (Online Interaction.), and I further consent to the electronic transmission and storage of my Personally Identifiable Health Information. I understand that I may withdraw this consent at any time without affecting my right to future care or treatment or risking loss or withdrawal of any program benefits to which I would otherwise be entitled. My practitioner has provided me with the opportunity to discuss and to question the issues, risks, and policies set forth in this consent form. I fully understand the information provided.

*Signature found on patient registration.

DRUG HISTORY CONSET CONSENT FORM FOR ePRESCRIBE PROGRAM

ePrescribing is way for practitioners to send electronically an accurate, error free, and understandable prescription from the practitioner’s office to the pharmacy. The ePrescribe Program also includes:

  • Formulary and benefit transactions - Gives the health care provider information about which drugs are covered by your drug benefit plan.
  • Fill status notification - Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled. 
  • Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality.

Medication history data can indicate:

  • compliance with prescribed regimens;
  • therapeutic interventions;
  • drug-drug and drug-allergy interactions;
  • adverse drug reactions;
  • and duplicative therapy.

The medication history information would include medications prescribed by other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.

Consent

By signing this consent form you are agreeing that your provider at the practice may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payors for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation.

Understanding all of the above, I hereby provide informed consent to the practice to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

*Signature found on patient registration.