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Before we begin, please take a few minutes to read our HIPPA Policy in place. (required) *

Notice of Privacy Practices As required by the Privacy Regulations Created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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.

A. OUR COMMITMENT TO YOUR PRIVACY  
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at this time.  

We realize that these laws are complicated, but we must provide you with the following important information:  
·  How we may use and disclose your IIHI
·  Your privacy rights in your IIHI
·  Our obligations concerning the use and disclosure of your IIHI               

The terms of this notice apply to all records containing your IIHI that are created or retained by our      practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintain in the future. Our practice will post a copy of our most current notice at any time.

B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:  
Administrator
2010 N. Loop W. Suite 260
Houston, TX 77018

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS

1. Treatment.
Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine test), and we may use the results to help us reach a diagnosis. 

We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your IIHI to the other health care providers for purpose’s related to your treatment.

2. Payment.
Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurance will cover, or pay for, your treatment. We also may disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services or items. We may disclose your IIHI to other healthcare providers and entities to assist in their billing and collection efforts.

3. Healthcare Operations.
Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your IIHI to bill you directly for services or items. We may disclose your IIHI to other healthcare providers or entities to assist in their healthcare operations.

4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.

5. Treatment Options.
Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.

6.  
Law Enforcement.
We may release your IIHI if asked to do so by law enforcement officials:

· Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
· Concerning a death we believe resulted from criminal conduct
· Regarding criminal conduct at our office
· In response to a warrant, summons, court order, subpoena or similar legal process
· To identify/locate a suspect, material witness, fugitive or missing person
· In an emergency, to report a crime (including the location of a victim(s) of the crime or the description, identity of location of the perpetrator)

7. Deceased Patients.
Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

8. Organ and Tissues Donation.
Our practice may release your IIHI to organizations that handle organs, eye or tissues procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.  

9. Research.
Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes EXCEPT WHEN an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following; (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

10. 
Serious Threats of Health and Safety.
Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

11. Military.
Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

12. National Security.
Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

13. Inmates.
Our practice may disclose your IIHI to correctional institutions or law enforcement offices if you are an inmate or under the custody of a law enforcement official. Disclosure for the purposes would be necessary: (a) for the institution to provide healthcare services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

14. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar programs.

D. YOUR RIGHTS REGARDING YOUR IIHI

You have the following rights regarding the IIHI that we maintain about you:

1. Confidential Communications.
You have the right to request that the practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care; such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of you IIHI, you must make your request in writing to OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555. Your request must describe in a clear and concise fashion:

·The information you wish restricted
· Whether you are requesting to limit our practice’s use, disclosure, or both; and
·To whom you want the limits to apply

3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555 in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee or the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of your denial. Another licensed healthcare professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment, your request must be made in writing submitted to OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555. You must provide us with a reason that supports your request (and the reason supporting your request) in writing. Also, we may deny your request if your request ( and the reason supporting that is in our opinion; (a) inaccurate and incomplete; (b) not part of the of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect or copy; or (d) not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” And “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor is sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003? The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice may notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555.

7Right to File a Complaint.
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact OB GYN Care at 2010 N. Loop W. Suite 260, Houston, TX 77018 (713)697-8555. All complaints must be submitted in writing.

7. Right to Provide Authorization for other uses and disclosures.
Our practice will obtain your written authorization for uses or disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact:

OB GYN Care,
P.A. 2010 N. Loop W.
Suite 260 Houston, TX 77018
713.697.8555


     
 
Great!, Now let's take a few minutes and go over our office policy. *

OBGYN Care  
Office Location:
2010 North Loop West Suite 260
Houston TX, 77018  

Contact Numbers:

Phone: 713-697-8555
Fax: 713-697-8551  

Office hours by appointment only
Monday 8:30 am 5:00 pm
Tuesday 1:30 pm – 5:00 pm
Wednesday 8:30 am-5:00 pm
Thursday 8:30-5:00 pm
Friday 8:30-12:00:pm 

OFFICE AND PAYMENT POLICY

Thank you choosing us as your primary Obstetrics & Gynecology provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop a payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance. We participate in most insurance plans including. If you are not insured by a plan we participate in, payment in full is expected at each visit. If you are insured by a plan we participate in but don’t have an up-to-date insurance card, payment in full for each visit is required until we verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any question you may have regarding your coverage. 

2. Co-payment and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. Please note that failure to pay your copay, deductible, or any past due balance at time of visit may result in your appointment being rescheduled, and possible release from our practice. If for some reason you feel you will not be able to meet this obligation, you may contact our Billing Office to discuss the possibility of a payment arrangement. 

3. 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 your insurers. You must pay for these services in full at the time of the visit. 

4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim. Please note that failure to supply us with proof of current/active insurance may result in rescheduling of your appointment. Fraudulent presentation of insurance coverage will result in immediate dismissal from our group. 

5. Claims submission. If we are in-network with your insurance, we will submit your claims and assist you in any way we reasonably can to help get your claims paid. If we are out-of-network with your insurance, then you must pay for visit at time of service. Once we enter the charge, we will send you a bill along with a receipt that you will need to submit to your insurance to receive reimbursement. 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. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. 

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. 

7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated by the billing department. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30 day period, our physician will only be able to treat you on an emergency basis. 

8. Late arrivals. We attempt to schedule our patient as efficiently as possible to reduce your waiting time in our reception area. If you arrive for your appointment more that 15 minutes late, we do reserve the right to reschedule your appointment for another day and time. 

9. Missed appointments. We politely request at least 24 hours notice. If you cancel in less than 24 we have a $30 fee associated with any appointment missed (no show), cancelled, or rescheduled within a 24 hour period. New Patient is a $150 fee. As a courtesy, we attempt to contact our patients to remind them of their appointments; however, it is the responsibility of the patient to arrive for their appointment on time. After three missed or broken appointment we reserve the right to politely ask you to receive medical care at another office. If you are a new patient, we will only allow you to miss or break your appointment with our office once. After that we are unable to provide medical care to you. We ask that you please try to understand our position on this delicate situation and kindly confirm your reserved appointment with our office no later than 24 hours before your appointment.

10. Workman’s Compensation:
Please be aware that OB/GYN Care may release information to Workman’s Compensation Board. 

11. Requests for Medical Records & Disability Forms.
Please allow at least ten (10) business days for completion of disability forms and copies of medical records. Payment is due prior to the completion of the forms. The following fees apply:Completion of disability forms will be subject to a $25 fee Copies of medical records $25. We must receive your completed Authorization for Release of Medical Records form in order to release your records.

12. Laboratory Services.
All of our specimens are sent to an outside lab. We contract with Lapcorp, Quest and Memorial Herman 

13. Prescription Refills. Please call your pharmacy to have them fax a refill request to our office at Fax# (713)697-8551 or they may send an electronic refill request.  Requesting a refill through your pharmacy allows us to more efficiently handle your request. Please allow at least a 72 hour notice in advance of requiring a refill. Please do NOT wait until you are almost out of medication before calling your pharmacy. Please note that refill requests will be completed within 48 business hours. Telephone prescriptions for pain medication and antibiotics will not be given after office hours or on weekends. Refills are reviewed by the provider and will only be filled at their discretion.

14. After Hours. We have an answering service that is available to our patient’s daily and the schedule is as follows: Monday-Friday 12-1:30PM (Lunch) 
After 5pm Monday-Friday, Weekends and Holidays. Please call for emergency issues. Refills, appointments and other non- emergent calls will be addressed during normal business hours.

15. Termination from our Practice. Our office values the relationships that have been established with our patient’s and wants to protect patients’ rights. We will only terminate patient relationships with cause and after careful consideration. Reasons for termination may include, but are not limited to: Repeatedly not showing for scheduled appointments Not complying with recommended medical care Hostile or abusive behavior toward/with our staff
Not paying bills in a timely manner.

16. OBGYN Care has a no children policy that should be observed. We care about the safety of your children being injured in the hallways.  You may be asked to reschedule if small children accompany you.


We accept the following methods of payment: CASH, CHECKS, VISA, MASTERCARD & DISCOVER. Returned checks are subject to a $35 service fee.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Notice of Privacy. Practices In keeping with the Health Insurance Portability and Accountability ACT, this notice describes how personal information collected in this office may be used and exchanged. Personal information includes: 1. 2. 3. 4. 5. Any information that identifies you. Any description of your health status, your age,
your sex, your ethnicity or demographic characteristics. We must
 purposes of payment or health care operations. In some cases, permission to share pertinent health information with another healthcare provider will be assumed.

You have the right to: Request restrictions on certain disclosures, while we are not obligated to agree to these restrictions we will honor them whenever possible. Inspect and copy your protected health information.
Amend protected health information. Obtain an accounting of disclosures of your protected health information, and
 Revoke the permission of disclosure although this would not apply to prior disclosures.

We are obligated to: Maintain the privacy of protected health information Provide this notice of our privacy policies
Abide by the terms of this notice 
Make public any changes to this notice obtain general consent from you to release any of this information for You have the right to register a complaint concerning any suspected violations of the privacy act with our office and/or with the Secretary of the Department of Health and Human Services (DHHS). There will be no retaliation against you if you file a complaint. If you need to file a complaint, speak to the Practice Administrator. They will take down your complaint and follow office procedures to investigate the problem. You will receive a follow up phone call once the complaint has been investigated. If you have any questions, please ask any staff member.

     
 
AUTHORIZATION FOR USE OF PATIENT'S EMAIL ADDRESS. *

AUTHORIZATION FOR USE OF PATIENT'S EMAIL ADDRESS BY PHYSICIANS AND BUSINESS ASSOCIATES:

OB-GYN CARE
 is committed to protecting information you provide us. OB-GYN CARE creates a record of the information you provide us for use in your care and treatment and for communicating with you. These records are maintained in a confidential manner, as required by law,  OB-GYN CARE, its professional staff, employees, volunteers, affiliated entities and business associates follow the privacy practices described in this consent. You are requested to provide your email address to OB-GYN CARE. The provision of your email address is entirely voluntary. Your email address may be used by OB-GYN CARE, its affiliated entities and business associates for the following, purposes: 

·For appointment reminders.
·To inform you of benefits and services related to your health.
·To allow you to communicate your opinion of our staff, facilities and services received.

As required by law and for certain law enforcement activities, Except as described above, we will not use or disclose your email address unless you authorize (permit) OB-GYN CARE in writing to disclose your email address. If you initially give permission, you may revoke that permission, which will be effective only after the date of your written revocation
     
 
Awesome, Now that you understand our policy's.
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Thank you, we understand you will be using only one insurance provider. Please fill out this form.
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Thank you, we understand you will be using more then one insurance provider. Please fill out this form.
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