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  • The Office of Dr. Vivian Asamoah

    Gastroenterology • Functional Medicine • Lifestyle & Nutrition
  • 25230 Kingsland Blvd., STE 101 Katy, TX 77494

    Phone: (281) 746-9284

    Fax: (832) 437-3206

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  • HIPAA Notice of Privacy Practices

  • To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. At the same time, Congress recognized that advances in electronic technology could erode the privacy of health information. Consequently, Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

    HHS published a final Privacy Rule in December 2000, which was later modified in August 2002. This Rule set national standards for the protection of individually identifiable health information by three types of covered entities: health plans, health care clearinghouses, and health care providers who conduct the standard health care transactions electronically.  Compliance with the Privacy Rule was required as of April 14, 2003 (April 14, 2004, for small health plans).
    HHS published a final Security Rule in February 2003. This Rule sets national standards for protecting the confidentiality, integrity, and availability of electronic protected health information. Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans).
    The Enforcement Rule provides standards for the enforcement of all the Administrative Simplification Rules.
    HHS enacted a final Omnibus rule that implements a number of provisions of the HITECH Act to strengthen the privacy and security protections for health information established under HIPAA, finalizing the Breach Notification Rule.

    FULL HIPAA RULE HERE

    Source

    https://www.hhs.gov/hipaa/for-professionals/index.html

    6/10/21

  • Acknowledgement of Review of Notice of Privacy Practices

  • I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. The information obtained by the office of Dr. Vivian Asamoah can and will be used to:

    ●Conduct, plan and direct treatment

    ●Obtain payment from third party payers

    ●Conduct normal healthcare operations such as quality assurance

    I have had the opportunity to read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I also understand the office of Dr. Vivian Asamoah has the right to amend this notice and that I am entitled to an updated copy of this notice if requested.

    I understand that I may request in writing to restrict how my health information is used or disclosed by the office of Dr. Vivian Asamoah to carry out treatment and healthcare operations. However, I understand that the facility may not accept these requested restrictions, but if accepted must abide by treatment.

    I understand that I have the right to review and copy my health information and request a change to any information that I believe is not a complete list of each disclosure of my protected health information.

  • I understand that a copy of the legal Power Of Attorney form must be provided to the office of Dr. Vivian Asamoah before services can be rendered.

  • I understand that I may revoke or terminate this authorization at any time by submitting a written request to the office of Dr. Vivian Asamoah, Attn: Privacy Officer.

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  • ACKNOWLEDGEMENT OF OFFICE FINANCIAL POLICY

  • It is the patient’s responsibility to provide us with the most current insurance and billing information to avoid any denial of claims. This includes but is not limited to new insurance policies, referrals from the patient’s PCP (if required) insurance, insurance policy changes, new identification cards, etc. If the claim has been denied, the patient will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship is with the patient, and not the patient’s insurance company. It is the patient’s responsibility to know and understand the coverage for the level of services under the patient’s insurance plan. We encourage all patients to contact their insurance companies, Employers, or Benefits Coordinators before services have been rendered to understand proper coverage. The office of Dr. Vivian Asamoah utilizes the services of Right Medical Billing for billing services. For questions pertaining to statements, claims, balances, and all other billing matters, please contact them directly at 832-705-7838.

  • ACKNOWLEDGEMENT OF OFFICE FINANCIAL POLICY

    It is the patient’s responsibility to provide us with the most current insurance and billing information to avoid any denial of claims. This includes but is not limited to new insurance policies, referrals from the patient’s PCP (if required) insurance, insurance policy changes, new identification cards, etc. 

    If the claim has been denied, the patient will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship is with the patient, and not the patient’s insurance company. It is the patient’s responsibility to know and understand the coverage for the level of services under the patient’s insurance plan. We encourage all patients to contact their insurance companies, Employers, or Benefits Coordinators before services have been rendered to understand proper coverage.      

    The office of Dr. Vivian Asamoah utilizes the services of Right Medical Billing for billing services. For questions pertaining to statements, claims, balances, and all other billing matters, please contact them directly at 832-705-7838


    ADMINISTRATIVE POLICY AND FEES

    Medical Records can be faxed to another physician’s office at no charge with a valid signed consent to release. 
    Requests for hard copies of Medical Records are subject to a $25 Administrative Fee. 
    Administrative forms that need to be completed by the physician (FMLA, Disability Forms, etc) are subject to a $25 administrative fee.

    THIRD PARTY BILLING

    The providers may find it medically necessary to recommend diagnostic tests from third party sources who may submit claims to the patient’s insurance. If diagnostic services such as labs, imaging, and specialty testing, are ordered by the providers, it is the patient’s responsibility to verify network coverage and benefits with their insurance. Please be advised that our office does not obtain insurance verifications or submit claims to the patient’s insurance for third party diagnostic services.

    MEDICAL RECORDS REQUESTS, FMLA, DISABILITY FORMS

    -Medical Records can be faxed to another physician’s office at no charge with a valid signed consent to release. 

    -Requests for hard copies of Medical Records are subject to a $25 Administrative Fee. 

    -New FMLA or Disability submissions: These require an office visit to evaluate the patient's necessity and work limitations.  This visit can be done by telephone and the patient’s copay will be charged along with a $40 administrative fee.

    -Renewing FMLA or Disability Forms: Patients will be charged a  $40 administrative fee payable in advance.

    CANCELLATION POLICY AND FEES

    Our office makes several attempts to remind patients of their appointments via phone calls, text, and email to confirm appointments in advance. The cancellation policy is as follows:


    - Office Visit Copays MUST be paid 48 hours in advance of the scheduled appointment, or the appointment WILL be canceled. Links for payment are provided with confirmation messages.  Payment can also be made over the phone during office hours. 

    -Appointments MUST be confirmed at least 48 hours in advance.  Unconfirmed appointments  WILL be canceled. 

    -Failure to notify the office of a cancellation ( “No Show”) to the appointment,  will result in a $25 fee.

    -There is a $25 fee for the cancellation or rescheduling of an office appointment without a 24 hours notice.

    -There is a $100 fee for the cancellation or rescheduling of a procedure, less than 24 hours notice.

    -Failure to notify the office of a cancellation (“No Show”)  of  IV Infusion appointment or cancellation less than 24 hours prior to the appointment, will result in a $100 fee due to personalized IV bag preparation.

    -All fees will be collected prior to rescheduling the appointment.

    I acknowledge that I have read and understand the financial policy of this medical office. I also understand and acknowledge that such terms may be amended by the practice without prior or written notice.

  • Please sign acknowledging your receipt and understanding of DVA Financial Policies

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  • AUTHORIZATION TO RELEASE OR OBTAIN HEALTH CARE INFORMATION

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  • I request and authorize the following practice:

    Name of Hospital / Provider:

    Phone Number:

    Fax Number: 

     

    To release and/or obtain medical records request below to:

    Dr. Vivian Asamoah

    25230 Kingsland Blvd., STE 101

    Katy, TX 77494

    281-746-9284

    Please fax records to 832-437-3206

    I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment of HIV (AIDS VIRUS), sexually transmitted diseases. psychiatric disorders / mental health, or drugs and/or alcohol use, you are specifically authorized to release all health care information relationf to such diagnosis, testing or treatment.

    This request and authorization applies to the release of records indicated below.

     

    FOR OFFICE USE ONLY

    Consult Notes Operative Notes ER Records Colonoscopy EGD Report Pathology Results
    Labs CT Results Ultrasound Results MRI Results Pill Cam All Records (Continuation of Care)

    Other:______________________________________________________________________________

    Note to Office: _______________________________________________________________________

     

     

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