I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments as an outpatient on a continuing basis and as an inpatient as necessary, as Dr. Bill L. Jou and staff may decide is advisable and necessary.  I am advised such treatment may include physical examination, laboratory procedures, biopsies, and other office procedures as well as inpatient procedures as required.  I understand that should I execute a Durable Power of Attorney for Health Care or other Advance Directive, I will provide an executed copy to Dr. Bill L. Jou.  I further understand that I will notify my physician of any changes in the Directive.  I understand that I will be informed about the course of my treatment.  Also, I am free to terminate my treatment with Dr. Bill L. Jou at any time.

 

FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for all charges, whether or not paid by my insurance(s), unless specifically exempted by my insurance company's contract with Bill L. Jou, M.D., Inc.  It is the patient's responsibility to know and understand their own insurance benefits.  This office will attempt to verify benefits, but is not responsible for misinformation or interpretation of benefits.  The patient will be responsible for deductibles, co-insurance, and non-covered services.  The patient will be responsible for all services for out-of-network claims.  It is the patient's responsiblity to inform this office if your insurance requires pre-certification or pre-authorization of services prior to scheduling of such services.  The patient will be responsible for all services denied by insurance due to "No Eligibility", "Non-Covered Service", "Pre-Authorization/Certification Not Obtained".  It is the patient's responsibility to inform this office of any change of information (e.g. address, telephone, insurance, etc.).  Statements are released after payment or denial of payment by your insurance.  If you don't feel your insurance processed your claim according to your benefits, you should contact your insruance.  Full payment is due within 30 days of statement.  Account will be subject to collection process, if not paid in full within 30 days.  Copayment fee is due at the time of office visit.  This office reserves the right to add late fees on past due accounts and the patient is responsible for all collection costs incurred to pursue collections for past due accounts.  A $25.00 feel will be charged for all checks returned as unpaid by your bank.  We reserve the right to charge a fee ($100 for new patients, $50 for returning patients) for cancellation of appointment with less than 24 hours notice.

 

ASSIGNMENT OF BENEFITS

I hereby assign medical and/or surgical benefits, private insurance, and any other health plan benefits to BILL L. JOU, M.D., INC.  I also authorize payment of medical benefits due me from any medical insurance to include Medicare, Medigap, or supplemental policy to be paid directly to the provider of service.  A copy of this assignment is considered valid as the original.

 

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize BILL L. JOU,M.D., INC. to release any medical information necessary to my insurance company or its agents in order to secure payments.  I also authorize BILL L. JOU, M.D., INC. to release any medical information to the physician referring me to this practice, and any pharmacies and vendors involved with securing medications and medical devices recommended to me by BILL L. JOU, M.D., INC.  I certify that I have read and fully understand the foregoing.  As the patient, the patient's guardian, conservator or general agent, I agree to accept the above terms.

 

ASSISTANCE WITH OBTAINING MEDICATION PRIOR AUTHORIZATION

Certain medications recommended by BILL L. JOU, M.D., INC. may require prior authorization from insurance companies.  I authorize BILL L. JOU, M.D., INC. to send my prescriptions for medications requiring prior authorizations to pharmacies familiar with that process to assist with expediting medication approval from the insurance company or pharmacy benefit manager.

 

NOTICE OF PRIVACY PRACTICES (MEDICAL)

 

THIS NOTICE DESCRIBES NOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used.  "HIPAA", provides penalties for covered entifities that misues personal health infomation.  As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.  We may use and disclose your medical records only for each of the following purposes:  treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.  An example of this would include a physical examination.

Payment means such activities as obtaining reimbursement for sevices, confirming coverage, billing, or collection activities, and utilization review.  An example of this would be sending a bill for your visit to your insruance company for payment.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.  An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.  We may contact you to provide appointment remiders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization.  You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you.  W are, however, not required to agree to a requested restriction.  If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us gby alternative means or at alternative locations.

The right to inspect and copy your protected health information.

The right to amend your protected health information.

The right to receive an accounting of disclosures of protected health information.

The right to obtain a paper copy of this notice from us upon request.