HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the
patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
- Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
- It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
- The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
- You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
- You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.
- Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
- We agree to provide patients with access to their records in accordance with state and federal laws.
- We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
- If you bring someone to your appointment, and voluntarily invite them into the appointment room, you hereby give the Dr. Athre and his employees consent to discuss your healthcare and relevant administrative and financial information in your guest’s presence. If you do not want such information discussed, it is your responsibility to please ask your guest to exit the room.
- Following surgery, Dr. Athre will need to discuss your healthcare and postoperative care with someone over the age of 18. If you bring someone to the office or to the operating room to pick you up, you have hereby given consent to discuss your healthcare with that person. Such discussions may include but are not limited to:
(1) what was done in the operating room,
(2) what needs to be done postoperatively,
(3) any complications in the operating room,
(4) postoperative appointments,
(5) prescriptions, and instructions for medications.
DO NOT BRING SOMEONE THAT YOU DO NOT WANT INFORMATION RELEASED TO.
Dr. Athre will not allow you to be discharged to a taxi service. If you have no relatives or friends that satisfy the above requirements, you can choose to be discharged to a service such as Cameo Caregivers. Again, your healthcare will be discussed with your caregiver to ensure that postoperative care is given to you appropriately. These services are HIPAA compliant and cannot release your information.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
PATIENT SURGICAL CONTRACT
In order to book the date of your procedure, a deposit of $1000 is required to be paid.
The deposit is required to secure the date of surgery. Surgery cannot be scheduled without your deposit. Acceptable forms of payment include cash, cashier checks, and credit cards. Patient finance plans with affordable monthly payments are also available. Payment of deposit is ONLY accepted by credit card, cashier’s check, or cash. Deposit payment is not allowed to be paid on a finance plan. Payments are accepted by phone, email invoice or in person. Total payment is due BEFORE your pre-operative appointment. $1000 – Deposit is NONREFUNDABLE without exception.
All surgical fees are due 21 days (3 weeks) prior to surgery.
If you schedule your surgical procedure less than 3 weeks (21 days) before the actual date of surgery, the full amount of the surgery fees will be required to pay at the time of scheduling.
If you decide to move your surgery to a different date and 2 weeks (14 days) advance notice is given, the entire amount will be applied towards the new date. If less than 2 weeks (14 days) notice is given, 50% of the surgical fees will be assessed as a penalty. We understand that extenuating circumstances come up; and hence, you will be allowed to reschedule your surgery once. If you reschedule your surgery a second time, your surgery will be cancelled and all funds paid will be forfeited.
Once your preoperative appointment is completed, and your invoice is completed, your surgery is NOT CANCELLABLE.
Any refunds awarded will be subject to processing fees. If credit card was used for payment, a 10% processing charge will be deducted from the refunded fees. If check or cash was used for payment, a $100 service charge will be deducted from the refunded fees. If financing company was used for payment, a 10% processing charge will be deducted from the refunded fees.
Your cosmetic quotation includes all post-operative care visits. If a touch-up procedure is required, the surgical portion of the touch-up will be discussed with you. Depending on the circumstances, the surgical fee may be offered for free or for a discount. YOU WILL BE RESPONSIBLE FOR ANY ANESTHESIA AND FACILITY ROOM FEES.
If your procedure requires the services of an anesthesiologist or needs to be done in an outpatient surgery center, you will receive a line-item expense for anesthesia and facility fee in your quotation. This fee is due to the outpatient surgical facility and IS AN ESTIMATE.
The facility and anesthesia fees are to be paid as directed by the surgical facility. Surgeon’s pricing will expire 90 days from the date of the original surgical cost analysis. Facility and anesthesia pricing expires 30 days from the date pricing is given. Refunds to a credit card will have a 10% processing fee on charges.
Raghu Athré, MD PA and Athré Facial Plastics does not accept third party insurance payments, nor does Dr. Athré file insurance claims.
You are free to file your own insurance claim if you choose to do so. Dr. Athré will provide you with your notes, initial consultation notes, operating room notes, operative dictation, and any pertinent photos/media.
YOU are responsible for:
- Obtaining the necessary preauthorizations
- Filing your own paperwork.
Dr. Athré is NOT responsible for:
- Contacting your insurance company
- Determining if preauthorization is necessary.
- Obtaining preauthorization
- Determining deductible and co-insurance payments
- Mailing documents to insurance companies
- Filing appeals on your behalf with insurance companies
Upon paying your surgical balance at Athré Facial Plastics and achieving a (0 – zero) balance, we consider your account complete, and we will not balance bill you for any services. If your case needs a pathologic specimen analyzed, your specimen will be sent to a board-certified pathologist for analysis. The approximate cash pay price for pathology is $250. However, you may consider filing insurance for your pathology. Again, this is your responsibility and questions regarding billing should be addressed to the pathology service provider.
If your case involves general anesthesia, you will get an ESTIMATE for services at the hospital. Any questions with respect to services rendered at the hospital should be addressed with the hospital directly. Dr. Athré has NO FINANCIAL RELATIONSHIPS WITH the hospital and cannot undo charges, etc.
Your procedure will require prescriptions medications such as antibiotics and pain medications. The medications that are prescribed are generic medications, and care has been taken to be as cost-conscious as possible. These medications ARE NOT INCLUDED in your estimate. On our last analysis using GOOD RX, etc. the combined cost of all medications is less than $50. Dr. Athré and his office has no way of knowing whether your medications will be covered under your insurance plan. Furthermore, IT IS NOT THE RESPONSIBILITY of the office to obtain preauthorizations for prescription medications. Medications such as injectable anesthesia medications ARE included in the cost of your surgery.
PATIENT FINANCING CONTRACT
The following letter details our office policies with respect to financing procedures.
- We offer Care Credit, Alphaeon, and United Medical Credit. These are 3rd party vendors that offer financing for medical procedures.
- There is a minimum invoice price of that varies based on financing provider. Please ask the office for details.
- In some of the credit programs, the physician is charged a fee. IF THE PATIENT CANCELS THEIR SURGERY, THE PATIENT IS RESPONSIBLE FOR THE FEES CHARGED TO THE PHYSICIAN.
- The contractual agreement for financing is between the patient and the appropriate financing company. Dr. Athre DOES NOT OFFER IN HOUSE FINANCING SERVICES. Furthermore, Dr. Athre has no vested interest in either of the above financing companies, nor does he receive any stipends.
Cases that are scheduled in holiday periods such as summer break, etc will have the terms “HOLIDAY SURGERY” on the quotation. Cases scheduled with less than 14 business days from date of scheduling and the date of surgery will have the term “QUICK SURGERY” on the quotation. In such cases, the entire surgical fee is due in order to schedule the surgery. In both cases, the surgery is non-cancellable, and nonrefundable after monies are paid and the invoice is complete. Any changes in date of surgery will incur a $1000 administrative fee.
Athré Facial Plastics uses text and email to communicate with our patients. We will text you reminders to your appointments. Furthermore, you will be automatically enrolled into our system for emailing and texting patients. Message and data rates may apply. You may stop at any time by replying with STOP to the appointment reminder message.
Appointment No-Show and Cancellation Policy
We appreciate all of our patients and we recognize that it can be difficult to schedule appointments on short notice. In order to be respectful to all of our patients, we have adopted the following policies with respect to rescheduling appointments and no-show’s.
Patients will be afforded a 15 minute grace period to their appointment time. If you are more than 15 minutes late to your appointment, your appointment will be scheduled and you will be charged a $150 no show fee. This fee may be charged to your credit card on file or may be a balance on your account that will need to be paid prior to scheduling additional appointments.
If you need to reschedule your appointment, please do so at least 48 hours (2 days) prior to your appointment. Rescheduled appointments with less than 2 days notice will also be charged the $150 administrative cancellation fee as described above.
Cancellations/rescheduled appointments due to medical reasons will be exempt from administrative charges with appropriate documentation from your healthcare provider.
Website Photography Disclaimer: Photography subjects on this website are professional models, and are not patients of Athré Facial Plastics, unless otherwise stated.