(303) 504-0600, Fax: (303) 504-0601
2121 S. Oneida St., Suite 248
Denver, CO 80224
Billing Desk: 720-949-6400
Notice & Acknowledgement of Privacy Policies & Procedures
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ THIS NOTICE CAREFULLY.
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), Family Centered Medicine, Inc. may not use or disclose your personal health information without your authorization.
The Practice has policies and procedures to comply with HIPAA laws. Every attempt has been made to keep the process for patients and staff as efficient as possible. However, the requirements are extensive and take time, effort, and cooperation to process each required task.
All patients are presented with certain notices and must sign certain forms. Depending on the course of treatment, some patients may be required to sign additional forms. The following is a summary of the most common notices and forms:
Notices of Privacy Act - This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Authorization for Use and Disclosure of Protected Health Information - The Practice may not use or disclose your health information for purposes other than treatment, payment or healthcare operations, without your authorization. Your
signature on this form indicates that you are giving permission to the practice for the use and disclosure of the health information listed on the form, for the purpose(s) listed on the form, to the people / organization(s) listed on the form. You may revoke this authorization at any time by signing the revocation section on your copy and returning it to Family Centered Medicine, Inc.
Complaint - You have the right to make a complaint about the Practice's privacy policies, procedures, or actions. The Practice will not engage in any discriminatory or other retaliatory behavior against you.
Request to Amend Protected Health Information - You have the right to request that health information that pertains to you be amended if you believe that it is incorrect or incomplete. The Practice will review your request and either grant your
request or explain the reason why it will not be granted. In the event that your request is not granted, you have the right to submit a statement of disagreement that will accompany the information in question for all future disclosures.
Request for Inspection of Protected Health Information - You have the right to request the opportunity to inspect and copy health information that pertains to you. The Practice will evaluate your request and will either grant it or explain the reason why the request will not be granted. In the event that your inspection request is not granted, you may request someone other than the person who originally denied the request to review the decision. If you request copies of the medical records, the practice reserves the right to charge you a reasonable fee for the expenses associated with copying the requested information.
Request for Accounting of Disclosures of Protected Health Information - You have a right to request an accounting of all non-routine disclosures of health information that pertains to you. Disclosures of health information associated with
treatment, payment, and healthcare operations or with prior patient authorization will not be accounted for.
Confidential Channel Communication Request - You have the right to request that communications concerning your personal health information be made through confidential channels. The Practice will do it's best to accommodate all reasonable requests.
Designation of Personal Representative - You may have the right to nominate one or more persons to act on your behalf with respect to the protection of health information that pertains to you. By making this request, you are informing the Practice of your wish to designate the named person as your personal representative. You may revoke this designation at any time by signing and dating the revocation section of the form available in our office and returning it to Family Centered Medicine, Inc.
Appointments: Please pre-schedule all appointments, including lab work. Time is allotted for your appointment based on your health care needs. Please tell the scheduling assistant if you feel you will need extra time with the provider. Necessary follow-up appointments should be made before you leave the office.
Billing Policy (Insurance & Third Party): As a courtesy, after payment of your copay when you checkout after your office visit, we will bill all major insurance carriers except Kaiser. To assist with this billing courtesy, you will be asked to confirm your insurance information on record, and for any updates to your personal contact information each time you visit our office. NOTE: Regretfully, we will NOT bill third parties such as workman's compensation, auto insurance, or others who may be libel for your medical expenses.
Payment at Time of Service & Cancellation Policy: Insurance copayments and any non-covered charges are expected to be settled at the time you checkout from your appointment. NOTE: A $50 fee may be charged for missed appointments, or appointments cancelled within 24 hours of your appointment time.
Cash Paying Patients: The basic office visit charge is $100 per visit, per person. Please expect additional charges for multiple visits, more than one person per visit, and ALL additional services ordered or provided.
Prescription Policy: New prescriptions always require an office visit and will NOT be ordered by the after hours provider on-call. For prescription refills, contact your pharmacy for fastest service. The pharmacy will contact our office for authorization. If your prescription is greater than three months old, an office visit will be necessary to renew the prescription. Antibiotics will NOT be renewed without a follow-up office visit.
Cell Phone Policy: As a courtesy to the staff and other patients, you are asked to set your cell phone to silent before entering the examination room.
Referral Policy: Our office is able to care for the majority of your healthcare needs. However, when care from a specialist is required, we will help with an appropriate referral. NOTE: it is up to you to determine if your insurance carrier will cover the charges from the referral provider. We generally do not manage patients in the hospital. Providers who are present in the hospital 24 hours each day will be responsible for your care, and will update our office regarding your condition.
FAMILY CENTERED MEDICINE