NOTICE OF PRIVACY PRACTICES
“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.”
(Effective Date: April 14, 2003; Amended September 23, 2013)
Complete Health is dedicated to protecting your health information. This Notice of Privacy Practices describes how we and the medical staff and personnel who provide you with care or services may use and disclose your Protected Health Information (“PHI”) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI, which is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and related healthcare services. We are required by law to maintain the privacy of your PHI, to provide notice of our legal duties and privacy practices with respect to your PHI, to notify affected individuals following a breach of unsecured PHI, and to abide by the terms of this Notice of Privacy Practices.
We may change the terms of our notice at any time. The new notice will be effective for all PHI that we maintain at that time. Upon your request, you can receive any revised Notice of Privacy Practices by accessing our website https://completehealth.com/ or by contacting the Practice’s Privacy Officer (contact information is below).
Privacy Officer
841 Prudential Ave., Suite 17
Jacksonville, FL
904-800-7071
1. How We May Use and Disclose Your PHI.
We may use or disclose your PHI as described in this section. The following are examples of the types of uses and disclosures of your PHI that our Practice is permitted to make without your specific authorization. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our Practice. Where state or federal law restricts one of the described uses or disclosures, we will follow the requirements of such state or federal law. The following are general descriptions only. They do not cover every example of disclosure within a category. However, all of the ways we are permitted to use and disclose your PHI will fall within one of the categories in this Notice of Privacy Practices.
Treatment.
We may use PHI about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other personnel who are involved in your care to, for example, plan a course of treatment for you. We also may disclose PHI about you to individuals outside of the Practice who may be involved in your medical care, such as family members or others we use to provide services that are part of your care.
Payment.
We may use and disclose your PHI as needed to obtain payment for the healthcare services we provide. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities. For example, obtaining approval for a medical procedure may require that your relevant PHI be disclosed to your health plan.
Healthcare Operations.
We may use or disclose your PHI as needed to support our business activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training of staff and conducting or arranging for other healthcare operations. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel and others to:
- Evaluate the performance of our staff;
- Assess the quality of care and outcomes in your case and similar cases;
- Learn how to improve our facilities and services; or
- Determine how to continually improve the quality and effectiveness of the health care we provide.
In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your healthcare provider is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. Please let us know if you do not wish to have us contact you concerning your appointment, or if you wish to have us use a different telephone number or address to contact you for this purpose.
We will share your PHI with third party “business associates” that may perform various activities (e.g., billing or transcription services) for the Practice. Whenever an arrangement between our Practice and a business associate involves the use or disclosure of your PHI, we will require the business associate to appropriately safeguard it.
2. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object.
We may use or disclose your PHI without your authorization in the following situations:
As Required By Law.
We may use or disclose your PHI to the extent that the use or disclosure is required by applicable law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by applicable law, of any such uses or disclosures.
Public Health.
We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability.
Communicable Diseases.
We may disclose your PHI, if authorized by applicable law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight Activities.
We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect.
We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI to the governmental entity or agency authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration (“FDA”).
We may disclose your PHI to a person or company required by the FDA to report information such as adverse events and product defects, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance.
Legal Proceedings.
We may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request, or other lawful process, but only if a reasonable effort has been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement.
We may release PHI for certain law enforcement purposes including, for example, reports required by law, to comply with a court order or warrant, or to report or answer questions about a crime.
Coroners, Funeral Directors and Organ Donation.
We may disclose PHI to a coroner, funeral director or medical examiner as necessary to permit them to carry out their duties.
Research.
We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Criminal Activity.
Consistent with applicable federal and state laws, we may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security.
When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President of the United States or other officials.
Workers’ Compensation.
Your PHI may be disclosed by us as authorized to comply with workers compensation laws and other similar legally established programs.
Required Uses and Disclosures.
Under the law, we must make disclosures to you and to the U.S. Department of Health and Human Services when required to determine our compliance with the requirements of the Federal Privacy Standards.
3. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent.
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, about your general condition or death. In addition we use or disclose your PHI to provide proof of immunization to a school that is required by state or other law to have such proof with agreement to disclosure by parent, guardian or other person acting in loco parentis of the individual, if the individual is an unemancipated minor. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.
4. Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization.
Other uses and disclosures not described in this Notice of Privacy Practices will be made only with your written authorization. For example, unless you provide written authorization, we will not use or disclose your PHI for marketing purposes and we will not sell your PHI. You may evoke your authorization at any time, but your revocation will only be effective for future uses and disclosures and will not affect any use or disclosure made in reliance on your authorization.
5. Your Rights.
Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights. We have the right to deny your request in certain circumstances. We will inform you if your request is denied.
Right to Access Your PHI.
You may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your healthcare provider and the Practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding; and, PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. If the information you request is maintained electronically, and you request an electronic copy, we will provide a copy In the electronic form and format you request, if the information can be readily produced in that form and format. If the information cannot be readily produced in that form and format, we will work with you to come to an agreement on form and format. IF YOU REQUEST AN ELECTRONIC COPY, PROVIDER HEREBY EXPRESSLY DISCLAIMS ALL DUTIES AND RESPONSIBILITY FOR THE SECURITY AND PROTECTION OF SUCH INFORMATION ONCE TRANSMITTED TO YOU AND HAS NO CONTROL OVER ACCESS TO THAT INFORMATION AFTER THE TRANSMISSION TO YOU THEREOF.
Please contact the Practice’s Medical Records Department if you have questions about access to your PHI. If you request a copy of the information, we may charge a fee for the costs of retrieving, copying, mailing and any other supplies associated with your request. Your records remain the property of the Practice.
Right to Request a Restriction on the Use or Disclosure of Your PHI.
You may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Except as provided in the following paragraph, we are not required to agree to your request. However, if we do agree to the request, we will honor the restriction until you revoke it or we notify you.
We will comply with any restriction request if (1) except as otherwise required by applicable law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the PHI pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full. The Practice is not responsible for notifying subsequent health care providers of your request for restrictions on disclosures to health plans for those items and services, so you will need to notify other providers if you want them to abide by the same restriction.
To request restrictions, you must make your request in writing to the Practice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).
Right to Request to Receive Confidential Communications From Us.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will attempt to accommodate reasonable requests. We will not request an explanation from you as to the basis for the request. Please make this request in writing to the Practice’s Medical Records Department.
Right to Request Amendment.
If you think that the PHI we have about you is wrong or incomplete, you may ask us to amend the information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the Practice’s Medical Records Department if you have a question about amending your medical record.
Right to Request an Accounting of Certain Disclosures.
You may request a list of our disclosures of your PHI, subject to several exceptions and limitations. For example, this right does not apply to disclosures for purposes other than treatment, payment or healthcare operations, and it excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. To request this list or accounting of disclosures, you must submit your request in writing to Practice’s Privacy Officer. Your request must state a time period that may not be longer than six years prior to the request date and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists during the same 12-month period, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any costs are incurred.
Right to Be Notified of a Breach.
You have a right to be notified in the event that we discover a breach of unsecured PHI, as defined under federal law.
Right to Obtain a Paper Copy of This Notice.
You have the right to obtain a paper copy of this notice, even if you agreed to receive such notice electronically. You may ask us to give you a copy of this notice at any time. To request a copy of this notice, you can make your request in writing to the Practice’s Privacy Officer (contact information is below).
Privacy Officer
841 Prudential Ave., Suite 17
Jacksonville, FL
904-800-7071
6. Questions and Complaints.
You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. For further information about the complaint process, or to make any requests or inquiries, you may contact our Privacy Officer at:
Privacy Officer
841 Prudential Ave., Suite 17
Jacksonville, FL
904-800-7071
AUTHORIZATION OF RELEASE
I agree to pay for all services rendered to me as a patient at Complete Health and hereby authorize release of medical information for processing insurance claims.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I authorize any holder of medical information about me to release said medical information requested by insurance companies with whom I have coverage or any public agency and its agents to determine benefits for services provided or benefits for related services.
ASSIGNMENT OF BENEFITS
I hereby authorize payment of benefits be made directly to Complete Health, for services provided to me by the Complete Health. I understand that I am financially responsible for charges not covered by this agreement. I authorize refund of overpaid insurance benefits where by coverage are subject to coordination of benefits. In the event of default, I agree to pay all costs of collection, including reasonable attorney fees of one third of the balance due.
FINANCIAL AGREEMENT
Thank you for choosing Complete Health as your health care provider. We are committed to providing you the best possible care. Your clear understanding of this financial agreement is important to our relationship and is an agreement between Complete Health and the Patient/Debtor names on this form. Our staff will be happy to discuss with you should you have any questions. Please read and sign this agreement prior to seeing the provider.
In this agreement the words “you’, “your”, and “yours” means the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us”, and “our” refer to Complete Health.
Insurance Eligibility: We participate in most insurance plans, including Medicare. Please be aware we only verify that you have active insurance and we can file a claim on your behalf. Our office does not verify what your specific plan covers. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
Proof of Insurance & ID: All patients must provide contact and insurance information before seeing the provider. We must obtain a copy of your state/government issued identification card and current insurance card to ensure proof of coverage. If you fail to provide us with the correct insurance card at the time of your appointment, this may result in self pay prices for your appointment.
Coverage Changes: If your insurance changes, please notify us prior to your appointment and bring your new insurance card when you check-in to help you receive your maximum benefit.
Co-payment, Deductible and Co-Insurance: It is your responsibility to pay any deductible, co-pay, co-insurance or any portion of the charge as specified by your plan. This is your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered non-compliant with the payer. Please help us remain compliant by paying your portion of the charges at each visit.
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 Medicare or other insurers (i.e labs requested with non payable diagnosis, visit with provider other than PCP, etc). You agree to pay any portion of the charges that is not covered by insurance.
Payment Plans: The business office can provide you with options on setting up a payment plan for large outstanding balances; you will need to leave a credit card on file for our office to run on the specified date each month until your balance is paid off.
Claim Submission: As a courtesy to you, we will submit your claims and assist in any way we reasonably can to help get your claims paid. We will file to your insurance policies provided. 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. If your insurance company does not respond within ninety (90) days, you are responsible for the remaining balance. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. We are also not responsible or to be involved in any disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance or the “usual and customary charges”.
Payments: Payment for services rendered are due at the time of service. Payments made will be posted directly to your account. Once your insurance has processed the claim(s) your payment will be applied to the claim. If your insurance covers a claim in full and you have overpaid, a credit will remain on your account to be applied to any outstanding or future balance.
Balances: Once we send you a statement, unless other arrangements are approved by us, the balance on your statement is due and payable upon receipt. We accept check, cash, and credit/debit cards. Please be aware that if a balance remains unpaid, we may refer your account to a collections agency and you may be discharged from the practice. If this occurs, you will be notified by regular or certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physicians will only be able to treat you on an emergency basis.
Laboratory: Due to varied contractual agreements between laboratories and health insurance plans, you are responsible to notify Complete Health if there is a specific laboratory you want utilized for the processing of any testing needs that the provider may order. Should you not specify a laboratory, Complete Health will process your specimen at either the in-house laboratory or send to one of the contracted laboratories. Should that lab selected by Complete Health not be a contracted entity with your insurance plan, you will be responsible for payment of any testing completed. Laboratory billing is separate from any billing generated in relation to the actual provider visit and the performing laboratory may/will send you an invoice directly should they not participate with your insurance plan. If requested, we will provide an estimated statement for any laboratory testing being ordered.
Returned Checks: There is a $35 fee for any checks that are returned from the bank. It is our policy to not accept a personal check for future appointments once a check has been returned.
ASF (Administrative Service Fees): Some forms are extensive and will require a fee of $25-$50 at the time of request. There are also some forms that may require an appointment prior to completion of the requested documents.
Self Pay: At a self pay visit there is a $100 minimum to be paid initially at check in. You will receive a bill for any amounts not collected at that visit based on services rendered. Once you have signed this agreement, you are stating that you hereby understand and agree to all the terms and conditions contained herein and guarantee payment of all services rendered.
COMPLETE HEALTH ASSOCIATES POLICY TO OUR PATIENTS
Statement of Policy: The physicians and staff of Complete Health share a common philosophy: Patients are to be treated not simply as customers but as partners working together to keep you healthy. We will do all we can to deliver you the best quality of medical care and pleasant patient experience. But we will also count on you to play your part in making collaboration a success.
Purpose of Policy: Complete Health has created this Policy to lay the groundwork for establishing and maintaining the best possible relationship with its patients, to set fourth our expectations, and to inform you of and protect your rights and responsibilities as a patient in accordance with a U.S. law called the 1998 Patients’ Bill of Rights Act, (copies of which are posted in prominent areas throughout the Complete Health facility (where patients can easily see them).
Your Rights As A Patient: As a patient of Complete Health, you have a right to:
- Receive medical treatment delivered without discrimination based on race, color, religion, national origin, gender, sexual orientation, disability, age, or marital status;
- Receive quality services that are appropriate to you care needs delivered in a timely manner;
- Receive treatment that is considerate, safe, dignified and respectful;
- Receive complete information from your physician about your diagnosis, treatment, evaluation, and prognosis in terms and language you understand;
- Know the identity and professional status of individuals providing medical services to you including the physician who has primary responsibility for you care;
- Change primary or specialty physician or be referred to another facility to the extent available;
- Refuse experimental treatments or procedures or participate in medical research;
- Complete an advanced directive setting out your wishes regarding your health care should you become incapacitated or unable to express your desires;
- Consult with a specialist at your request and expense;
- Be notified by your physician about the medical risk associated with your treatment and other medically relevant information necessary to enable you to give informed consent before receiving the treatment ;
- Refuse treatment and participate in decisions involving you your health care (expect when such participation is contraindicated for medical reasons);
- Seek a second opinion with regard to your treatment;
- Have your medical records, history, and other personal health and private information kept confidential and not collected, used, or disclosed without your authorization ( except where Complete Health is permitted or required by law to collect, use or disclose that information without your authorization);
- Not have your care interrupted should your treating physician leave Complete Health
- Obtain access to your medical records, history, and other personal health and private information;
- Be billed fairly in accordance with the terms set out in the Complete Health Policy;
- Examine and receive an explanation of your financial obligations regardless of who pays for your treatment;
- Ask questions and express concerns, complaints, grievances or comments regarding your medical treatment, billing or any other any other aspects of your experience as a patient of Complete Health.
PATIENT’S RESPONSIBILITIES TO COMPLETE HEALTH
- Knowing about the terms of insurance plan, including the benefits it covers;
- Scheduling appointments within a timely manner;
- Furnishing Complete Health accurate and up-to-date information about your current complainants, medical history, medications, allergies, insurance and other pertinent data;
- Showing up on time for all appointments with copayments at check-in;
- Notifying Complete Health at least 24 hours in advance when you are unable to keep a scheduled appointment, if abuse is determined be prepared to pay no show fees;
- Listening to your physicians, following the terms of the treatment they prescribe, and asking questions if you don’t understand their instructions;
- Immediately notifying your physician of important change in your conditions or after you receive emergency care;
- Treating all Complete Health physicians, staff, fellow patients, and visitors with courtesy and respect;
- Obeying all health and safety regulations when you come on with Complete Health, including the ban on smoking.
PATIENT TERMINATION POLICY
Statement of Policy: To provide the best quality medical care and a pleasant patient experience, all patients are expected to carry out their responsibilities under the Complete Health Patient’s Rights and Responsibilities Policy. Complete Health reserves the right to terminate any patient who fails to meet these responsibilities.
Purpose of Policy: Complete Health regards the termination of a patient as a last resort to be used only after attempts to resolve problems prove unsuccessful. The purpose of this Policy is to explain the grounds and procedures for termination. Our hope and expectation is that by making patients aware of the termination process, Complete Health will never have to actually resort to it.
Grounds for Termination:
- Termination for Misconduct: Complete Health may terminate patients for behavior that it believes permanently and irreversibly damages the physician-patient relationship and the respect on which it rets, Including a patient’s:
- Persistent refusal to follow prescribed treatment protocols and procedures;
- Tampering, alerting , improper or illegal use of prescriptions or medications;
- Lying, furnishing false information, or misrepresenting the truth;
- Acting in violent, harassing or abusive way to Complete Health physicians, staff, patients, or visitors;
- Theft of any Complete Health property;
- Persistent failure to pay bills and honor financial obligations under the Complete Health policy;
- Persistent failure to keep appointments and not rescheduling appointments in a timely manner;
- Termination for Medical Reasons: Complete Health may also terminate patients for medical reasons to the extent it determines that continuing to treat the patient the patient is no longer necessary or beneficial to the patient’s health and termination of treatment is in the patient’s best interest.
- Immediate Termination: Complete Health reserves the right to immediately terminate patients who commit offenses that it deems to be intolerable. For example, patient can be terminated engaging in acts physical violence even if it is a first offense.
- Termination Letter: Complete Health will send any patient terminate in accordance with this Policy a letter listing:
- A statement of the reason (s) for termination;
- The date on which the termination takes effect.
- Termination Must Not Harm Patient’s Heath: Complete Health will give terminated patients a grace period of up to 30 days to find a new physician and make appropriate treatment arrangements before the termination takes effects.
By signing this document you have received, read, and understand the information provided above. If you have any questions, please contact a member of management before signing.
COMPLETE HEALTH POLICY TO OUR PATIENTS
Statement of Policy: The physicians and staff of Complete Health share a common philosophy: Patients are to be treated not simply as customers but as partners working together to keep you healthy. We will do all we can to deliver you the best quality of medical care and pleasant patient experience. But we will also count on you to play your part in making collaboration a success.
Purpose of Policy: Complete Health has created this Policy to lay the groundwork for establishing and maintaining the best possible relationship with its patients, to set fourth our expectations, and to inform you of and protect your rights and responsibilities as a patient in accordance with a U.S. law called the 1998 Patients’ Bill of Rights Act, (copies of which are posted in prominent areas throughout the Complete Health facility (where patients can easily see them).
Your Rights As A Patient: As a patient of Complete Health, you have a right to:
- Receive medical treatment delivered without discrimination based on race, color, religion, national origin, gender, sexual orientation, disability, age, or marital status;
- Receive quality services that are appropriate to you care needs delivered in a timely manner;
- Receive treatment that is considerate, safe, dignified and respectful;
- Receive complete information from your physician about your diagnosis, treatment, evaluation, and prognosis in terms and language you understand;
- Know the identity and professional status of individuals providing medical services to you including the physician who has primary responsibility for you care;
- Change primary or specialty physician or be referred to another facility to the extent available;
- Refuse experimental treatments or procedures or participate in medical research;
- Complete an advanced directive setting out your wishes regarding your health care should you become incapacitated or unable to express your desires;
- Consult with a specialist at your request and expense;
- Be notified by your physician about the medical risk associated with your treatment and other medically relevant information necessary to enable you to give informed consent before receiving the treatment ;
- Refuse treatment and participate in decisions involving you your health care (expect when such participation is contraindicated for medical reasons);
- Seek a second opinion with regard to your treatment;
- Have your medical records, history, and other personal health and private information kept confidential and not collected, used, or disclosed without your authorization ( except where Complete Health is permitted or required by law to collect, use or disclose that information without your authorization);
- Not have your care interrupted should your treating physician leave Complete Health
- Obtain access to your medical records, history, and other personal health and private information;
- Be billed fairly in accordance with the terms set out in the Complete Health Policy;
- Examine and receive an explanation of your financial obligations regardless of who pays for your treatment;
- Ask questions and express concerns, complaints, grievances or comments regarding your medical treatment, billing or any other any other aspects of your experience as a patient of Complete Health
PATIENT’S RESPONSIBILITIES TO COMPLETE HEALTH
- Knowing about the terms of insurance plan, including the benefits it covers;
- Scheduling appointments within a timely manner;
- Furnishing Complete Health accurate and up-to-date information about your current complainants, medical history, medications, allergies, insurance and other pertinent data;
- Showing up on time for all appointments with copayments at check-in;
- Notifying Complete Health at least 24 hours in advance when you are unable to keep a scheduled appointment, if abuse is determined be prepared to pay no show fees;
- Listening to your physicians, following the terms of the treatment they prescribe, and asking questions if you don’t understand their instructions;
- Immediately notifying your physician of important change in your conditions or after you receive emergency care;
- Treating all Complete Health physicians, staff, fellow patients, and visitors with courtesy and respect;
- Obeying all health and safety regulations when you come on with Complete Health, including the ban on smoking.
By signing this document you have received, read, and understand the information provided above. If you have any questions, please contact a member of management before signing.
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