Personal Injury Protection (PIP) Billing

What is PIP?   

• Personal Injury Protection is a part of your auto insurance policy. It is designed to take care of you
immediately after an accident.
• If you have PIP, you MUST use it. Your health insurance will not cover your expenses if you have PIP.
• If you were not the “at-fault” party, your PIP will be reimbursed by the 3rd party.

Benefits of PIP

• PIP is no-fault, so it doesn’t matter who caused the accident…you’re still covered.
• Most PIP coverage is for 3-years or $10,000, whichever comes first. Some policies have higher limits.
• PIP covers medical payments, wage loss, and loss of services.
• There is no deductible. There are no co-pays.

What is Med Pay?

• Med Pay is a medical-payments-only version of PIP. It does not cover wage loss or loss of services.

A Step-By-Step Guide

1. Call YOUR insurance agent. Ask if you have PIP or Med Pay.
2. If “NO”, ask for a copy of the document you signed waiving PIP benefits.
3. If yes, ask about limits on time and dollar amount.
4. Ask your agent to take your report of loss and call it into the claims office.
5. Ask your agent to call back with the claim number, address and phone of the claims office.
6. Call the claims office and get the name of the claims adjuster handling your claim.
7. Ask the claims adjuster to mail a PIP Application, Attending Physician’s Report, and Salary Verification forms.
8. Complete the PIP Application and return it to the claims adjuster.
9. Have your chiropractor fill out the Attending Physician’s report form and return it to you and mail it to your
   claims adjuster.
10. Have your employer complete the Salary Verification form and return it to you and mail it to your claims
    adjuster.
11. Provide your claim number, adjustor’s name, office address and phone number in the space provided below.

Clinic Policy

Welcome to the Asa Acupuncture and Oriental Medicine. We want you to be comfortable and to receive the best care possible. Please do not hesitate to ask any questions you might have regarding your visit, your billing, or our policies.

PAYMENT
I understand that I am fully responsible for the payment of fees associated with services I receive at Asa Acupuncture & Oriental Medicine Clinic.

INSURANCE
It is my responsibility to confirm that my insurance coverage will adequately cover any treatments I receive at ASA Acupuncture. If I wish to bill my insurance, I understand insurance policies may vary greatly in terms of deductible and percentage of coverage for services at this clinic. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, Copays, as well as any unpaid balances in this office.
We will do our best to verity your insurance coverage, and will bill your insurance in a timely manner. If your insurance carrier sends payments to you for services rendered in this office, you agree to send or bring those payments to this office upon receipt. If you pay for your visits in full, then the payments should be sent directly to you from the insurance company. If your insurance carrier sends payments to you for services rendered in this office, you agree to send or bring those payments to this office upon receipt. If your insurance company requires medical reports or records to document your treatment or progress, your signature below authorizes this office to release the medical information necessary to process your claim.

I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Policy. I understand that if I have questions or complaints regarding my privacy rights that I may contact the office. I further understand that the practice will offer me updates to this Notice of Privacy Policy should it be amended, modified, or changed in any way.

HEALTH CONDITIONS and MEDICATIONS
I understand I must report all past and pre-existing health conditions to my health practitioner. I also understand that I am required to report if I suspect, am planning or am currently pregnant or have pacemaker to my health practitioner prior to treatment. I promise to report all current medications/supplements. I also will notify my practitioner of any changes or updates with my health or medications/supplements. I understand the risks and will take responsibility if I fail to do so.

ELECTRONIC COMMUNICATION DISCLOSURE
While the clinic strives to maintain security, the electronic system including email, text and messaging services by ASA Acupuncture & Oriental Medicine are not encrypted and so does not adhere to HIPAA standards. You may choose to opt out of receiving alerts with personal health information.

NOTICE OF PRIVACY POLICY

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

OUR RESPONSIBILITIES

The law protects the privacy of the health information we create and obtain in providing care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information related to these services. Federal and state laws allow us to use and disclose your protected health information for purposes of treatment, payment, and health care operations.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

For Treatment: Information obtained by a licensed provider or other member of our healthcare team will be recorded in your medical record and used to help decide what care may be right for you. For example, your physician may need to consult with specialists about your care. Information about you would be shared with other providers to help understand your care needs.

For Payment: When we request payment from your health plan or other payers, they need information from us about your medical care such as diagnoses, procedures performed, or recommended care in order to cover the services provided to you. For example, we may need to give your health plan information about your therapy you received so your health plan will pay us or reimburse you for the procedure. We will not disclose your health information to third party payers without your authorization unless allowed to do so by law.

For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to make sure that all of our patients receive quality care. For example:

• We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.

• We may disclose information to physicians, student clinicians, medical assistants, technicians, or other clinic personnel for review and learning purposes.

• We may use and disclose your information to conduct or arrange for services, including medical quality reviews; accounting, legal, risk management and insurance services; and audit functions, including fraud and abuse detection and compliance programs.

OTHER USES AND DISCLOSURES

Clinic Directory: Unless you notify us that you object, we may use your name, location in the facility, and general condition for directory purposes. Directory information may be provided to people who ask about you by name. This information also includes your appointment dates. No medical information, including your chief complaint or the nature of your care, will be disclosed as part of directory information.

Communication with Family and Friends: We may release medical information about you to a family member or friend who is involved in your care and/or helps pay for your care. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat.

YOUR HEALTH INFORMATION RIGHTS

Right to this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy at any time.

Right to Inspect and Copy: You have a right to inspect and receive a copy of certain health care information including certain medical and billing records. To obtain a copy of your records you must submit your request in writing on an official authorization form to ASA Acupuncture & Oriental Medicine. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you would like to schedule an appointment to view your record or if you have any questions about your right to inspect and copy your record.

Note: We are required to retain our records of the care that we provided to you. Although you have the right to exercise control over certain uses and disclosures of your medical information, the medical record maintains on your care is property of ASA Acupuncture & Oriental Medicine may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical record, you may request that the denial be reviewed. We will comply with the outcome of the review.

Right to Request Amendment: You have a right to ask that your health information be amended by sending a written request. We have the right to deny this request under certain circumstances. You may write a statement of disagreement if your request is denied. This statement of disagreement will be stored in your medical record, and included with any release of your records.

Right to a List of Disclosures: You have the right to request a list of disclosures. This is a record of certain disclosures we made of medical information about you in accordance with applicable laws.

You must submit your request in writing to our to obtain a list of disclosures. The first time you request a list within a 12 month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restriction: You have a right to ask us to restrict certain uses and disclosures of your health information. You may be asked to make this request in writing. Ask your caregiver if you have questions about this. We will comply with all reasonable requests.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a specific way or location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may be asked to make your request in writing. Ask the person (or department) that gave you this notice for more information about this process. We will comply with all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Revoke Authorization: Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you under these circumstances, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and information disclosed to other party’s may no longer be afforded certain protections under the law once released and might be re-disclosed to other parties without your authorization.

Changes to this Notice: We reserve the right to change this notice at any time. Any revised or changed notice will be effective for medical information we already have about you as well as any information we receive in the future.

Complaints: If you believe your privacy rights have been violated, you may contact ASA Acupuncture & Oriental Medicine. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

ASA Acupuncture & Oriental Medicine records health care services we provide you. You may ask to see and copy of your record. You may ask to correct the record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so.

CONSENT FOR TREATMENTS

East Asian medicine means a health care service using East Asian medicine diagnosis and treatment to promote health and treat organic or functional disorders. As outlined in the legal scope of practice of licensed practitioners in Washington state, I understand that these methods of treatment may include but are not limited to the following: Acupuncture, Cupping, Point Injection Therapy, Therapeutic massage/Tuina, Electroacupuncture, Heating Lamp or Heat Pad, Herbal Patches, and Chinese herbal medicine.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling site that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ punture, including lun puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. 

I understand that while this doctument describe the major risk of treatment, other side effects and risk may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommoneded are tranditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking hernbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tonhue. I will notify a clinical staff memebr who is caring for me if I am or become pregnant.  

I hereby release ASA Acupuncture and Oriental Medicine from any and all liability that may occur in connection with the above mentioned procedures except for failure to perform those procedures with appropriate medical care. I understand I am free to withdraw this consent and discontinue participation in these procedures at any time. If a referral is required in order for me to be seen in this office, I am responsible for making sure all referrals are current.

CANCELLATION POLICY

As a courtesy to our office and other patients, we ask that you please notify the office at least 48 hours in advance if you need to cancel or reschedule your appointment. You will be charged a $40.00 fee for any missed appointment or cancellation giving less than 48 hours notice for any non-emergency situations.

FINANCIAL AGREEMENT/ASSIGNMENT OF BENEFITS

I understand that I am responsible for paying all non-insurance-related fees at the time services are rendered, including herbs and other supplements. If I choose to use my insurance, I acknowledge that I am responsible for all “non-covered” services, as well as any co-insurance or co-payments associated with my visit.

I authorize the insurance payment of medical benefits directly to ASA Acupuncture & Oriental Medicine. However, there is no guarantee of benefit coverage, and if my insurance denies payment for any claims submitted, I will be responsible for the full payment. I may contact my insurance company directly to resolve any disputes.

Please note that we do not bill your secondary insurance. It is important to inform us if you have both primary and secondary insurance to ensure proper coordination of benefits. However, I understand that I will need to handle any claims or payments with my secondary insurance provider directly.

By signing below, I agree to comply with the office policies stated above, which I have read and understood. I also authorize the use of this agreement for all insurance submissions.