Payment on Account
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NOTICE OF HEALTH INFORMATION & FINANCIAL POLICIES
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
COMMITMENT TO PRIVACY:
1st Line Medical, Inc. is dedicated to maintaining the privacy of your healthcare information and we are required by law to maintain the confidentiality of information that identifies you. Any use of healthcare information beyond the uses described below requires your individual written authorization. The Health Insurance Portability and Accountability Act (HIPAA) obligates us to provide you with a copy of our Privacy Notice, outlining our privacy practices and how we safeguard your health information. We abide by the terms of the Privacy Notice currently in effect, and reserve the right to revise or amend the notice, as needed.
YOUR HEALTH INFORMATION RIGHTS:
Although your health record is the physical property of the healthcare facility that compiled it, the information belongs to you. You have the right to:
• Request a restriction on certain uses and disclosures of your information;
• Obtain a paper copy of the notice of privacy practices;
• Inspect and copy your health care record;
• Obtain an accounting of disclosures of your health information;
• Request confidential communication;
• Amend your healthcare record;
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
We will use your health information for payment.
In order to determine your eligibility for services, we will contact your insurance company and disclose healthcare related information. Also, we may bill you or a third-party payer for services that you receive from our company. The health information that identifies you, your diagnosis, equipment, and supplies may be included on this bill.
Responsibility for Payment:
1st Line Medical, Inc. will make every effort to bill your insurance company directly. You are responsible for full payment for services rendered by us. Any charges not covered by your insurance company, including co-payments, deductibles, non-covered services, and out-of-network services will be your responsibility except where not allowed by law. It is your responsibility to know the requirements of your health plan. In the event of a denial of any insurance billed, you will be responsible for all fees charged.
To our Managed Care Patients:
If you receive any services at 1st Line Medical, Inc. and the fees are denied because you did not obtain prior authorization from your primary care physician, you will be personally responsible for those fees. We will use your health information for healthcare operations. We may use your health information to evaluate the quality of care you receive from us, to conduct cost management assessments, and to plan business activities. This information is used in an effort to continually improve the quality and effectiveness of the healthcare services we provide.
Business Associates: There are some individuals who are under contract with us and, from time to time, are engaged in the improvement or financial enhancement of our business. So that your health information is protected, however, we require any business associate to appropriately safeguard your information.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.
Health Oversight Activities: We may disclose health information to health oversight agencies for activities authorized by law, including surveys, audits, and compliance inspections.
Worker’s Compensation: We may release your health information to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
We are required to:
• Maintain the privacy of your health information;
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you;
• Abide by the terms of this notice;
• Notify you if we are unable to agree to a requested restriction;
• Accommodate reasonable requests you may have to communicate health information by alternative means.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.
Should our information practices change, we will mail a revised notice to your address on file. We will not use or disclose your health information without your authorization, except for treatment, payment, and healthcare operations.
We will use your health information for treatment.
Information obtained by our company will be documented in your healthcare record and will be used to provide you with healthcare related services. The prescription that your physician has ordered will be part of the record and will determine the equipment and supplies that you receive.