Rights and Responsibilities of the Patient

Phinney Primary Care & Wellness has adopted the following rights and responsibilities for our patients.

As a patient of Phinney Primary Care & Wellness, you have the following rights:

1. The right to be treated with dignity and respect
2. That all comments and records will be treated with strict confidentiality. You will be given the opportunity to approve release of any information, consistent with the law.
3. The right to be provided with information concerning your diagnosis, treatment and prognosis.
4. The right to be given the opportunity to participate in decisions related to your health care
5. The right to informed consent previous to treatment except in case of emergency
6. The right to refuse treatment, you will be informed of the consequence of your actions.
7. The right to privacy.
8. The right to reasonable responsible service
9. The right to refuse to participate in experimental research.
10. The right to continuity of care.
11. The right to examine and to receive an explanation for your bill.
12. The right to report problems you may have concerning services received without fear of service being denied.
13. The right to services that will not be denied because of your race, sex, or nationality.
14. The right to examine our fee schedule.

 

As a patient of Phinney Primary Care & Wellness, you have the following responsibilities:

1. You are responsible for considerate and respectful treatment towards other patients and clinic personnel.
2. You are responsible for providing Phinney Primary Care & Wellness with accurate and complete information regarding your present intake of medication and past medical information.
3. You are responsible for notifying the Phinney Primary Care & Wellness staff when you do not understand the instructions given to you.
4. You are responsible for the consequences of refusing treatment or not complying with therapy, once the consequences have been explained to you.
5. You are responsible for keeping appointments, complying with therapy and following treatment.
6. You are responsible for being on time for your appointments and providing us with the documentation necessary to assist in determining your payment status.
7. You are responsible for fulfilling your financial obligations.

 

Patient Consent for Use and Disclosure of Protected Health Information

1. I hereby give my consent for Phinney Primary Care & Wellness to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO). (The Notice of Privacy Practices can be provided by Phinney Primary Care & Wellness and describes such uses and disclosures more completely.)
2. I have the right to review the Notice of Privacy Practices prior to signing this consent. Phinney Primary Care & Wellness reserves the right to revise its Notice of Privacy Practices at any time.  A revised Notice of Privacy Practices may be obtained by forwarding a written request to Dr. David Harvey, Phinney Primary Care & Wellness, 6804 Greenwood Ave N, Seattle, WA 98103.
3. With this consent, Phinney Primary Care & Wellness may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including lab results, among other things.
4. With this consent, Phinney Primary Care & Wellness may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
5. With this consent, Phinney Primary Care & Wellness may email me any items that assist in carrying out TPO, such as appointment reminders and patient statements.  I have the right to request that Phinney Primary Care & Wellness restrict how it uses or discloses my PHI to carry out TPO.
6. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
7. By signing this form, I am consenting to allow Phinney Primary Care & Wellness to use and disclose my PHI to carry out TPO.  I also acknowledge that I have been given the opportunity to review the Notice of Privacy Practices for Phinney Primary Care & Wellness.
8. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.  If I do not sign this consent, or later revoke it, Phinney Primary Care & Wellness may decline to provide treatment to me.

 

Patient Financial Obligation Agreement & Payment Policy

Insurance. We participate in most insurance plans. To verify if your provider is in network with your insurance, please contact your insurance company directly. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we do participate with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Insurance coverage is not a guarantee of payment for services provided by the healthcare provider. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments and Deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Co-payments mandated by your insurance company may not be printed on the insurance card. It is your responsibility to notify the front desk administrator upon arrival that a co-payment is due.

Proof of Insurance. All patients must complete our patient registration form before seeing the provider. We will make a copy of your identification and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Claims Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid, including, but not limited to, releasing all information necessary to secure the payment of benefits. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Procedure Coding. Your healthcare provider assigns Current Procedural Terminology (CPT) codes according to the services provided and does their best to ensure that the most appropriate codes that also provide the highest amount of coverage are sent to your insurance company. Insurance companies may request that providers change coding for a visit for it to be covered. It is not our policy to change coding that has already been submitted.

Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Preventative Visits. If you are here for a scheduled preventative medicine visit (a.k.a. a well-visit, preventative, check-up, or annual physical exam), this visit will be submitted as a preventative exam to your insurance. Depending on your health plan’s policy, your insurance may or may not cover this visit. Most (but not all) insurance companies cover well visits, or you may have a maximum annual cap for well benefits that is less than our charges. If the physician addresses and documents an acute or problem-related issue during the course of your preventive exam, you may also receive a separate charge for an office visit on the same day.

Non-Covered Services. Please be aware that some and perhaps all of the services you receive may be non-covered or not considered reasonable or necessary by your insurance. You are responsible to pay for these services.

Self Pay. If you do not have insurance, payment is due in full at the time of service.

Non-Payment. Payment is due upon the receipt of the monthly statement. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. Returned checks or credit card payments due to insufficient funds are subject to a $40.00 handling fee for each submission.

Missed Appointments. A no show appointment without 48 hours advance notice is subject to a $150.00  fee for 30 minute appointments and $250.00 fee for 60 minutes appointments. These charges will be your responsibility and billed directly to you.

Credit Card Security: All patients are  required to have a valid Credit Card on file for billing. Your credit card information will be stored in our secure Elation EHR and Tebra Billing System. We are using Stripe to take your credit card payments. Stripe encrypts sensitive data both in transit and at rest. Stripe's infrastructure for storing, decrypting, and transmitting primary account numbers (PANs), such as credit card numbers, runs in a separate hosting infrastructure, and doesn't share any credentials with other services. Please visit https://phinneypcw.com/billing-protocal-update-in-detail/ for details. The credit card will be used for same day Copays, Self Pay visits and 30- day past due balances on patients' accounts. 

 

Copyright © 2008 by the American Academy of Family Physicians. All rights reserved.