PROFESSIONAL FEES AND PAYMENT – Fees are based on the level of training, complexity of the problem, and time spent. They are within the range of fee guidelines and most insurance company allowables. Please feel free to discuss billing concerns and questions with the Office Manager. Professional fees for services rendered are due prior to leaving the office. You may pay by cash, check, money order or credit card (American Express, Discover, MasterCard and Visa). In rare circumstances, payment arrangements may be considered after discussion with the Office Manager or Practice Administrator. There will be a $35 fee for checks returned by your bank. Interest will accrue on past-due balances at the rate of 12 percent per annum. If your account is referred to a collection agency or to an attorney for non-payment, you agree to pay a pre-suit collection fee equal to 35% of the past-due amount plus our attorney’s fees and court costs if we have to file a lawsuit against you for nonpayment.
INSURANCE –We participate in most managed care plans, and we will bill your insurance plan as necessary. If we accept your insurance,you will be responsible for any co-payment and any unmet deductible on the day of service, and we will bill your insurance for the remainder. You are responsible for any service that is not covered by your insurance plan. If we do not participate with your managed care plan, the office will request payment in full at the time of service, unless other arrangements have been made with the Office Manager in advance. We may be able to bill your plan as a courtesy to you and credit your account if we receive any additional payment. If you are without health insurance and you are enrolled in the Jefferson Independence Card (http://www.jeffersonicard.com), your bill may be substantially reduced at the time of service. Knowing your insurance benefits and any restrictions or limitations (eligibility,covered benefits and medically necessary procedures) is your responsibility. Please contact the customer service department at your insurance company for questions regarding your coverage. You are responsible for any services not covered by your plan.
· Proof of Insurance - All patients must complete and/or update his or her demographic and insurance information at each office visit, using an electronic check-in pad. You must furnish valid and up-to-date proof of insurance coverage. If you provide false or expired insurance information, you will be responsible for the balance of the claim. Please notify us of any changes in insurance coverage prior to your scheduled appointment. Insurance denials due to termination of coverage will be billed to you automatically.
· Co-Payments, Co-Insurance and Deductibles – All co-payments must be paid before leaving the office. Deductibles and co-insurance will be billed to you after the insurance company has processed your claim. By contractural law, protection of your insurance benefits requires us to charge for, and you to pay for, all required co-payments, co-insurance, deductible and non-covered services.
· Claim Submission – In most cases, we will submit your insurance claims and will assist you in any way reasonable to help get your claim paid. Your insurance company may need you to supply information directly to them. It is your responsibility to comply with their request in a timely manner. Texas insurance law requires your insurance to provide timely payment. Please be aware that the balance of your claim is your responsibility to pay, whether or not your insurance company has paid. We are not a party to your insurance contract.
· Referrals – If your managed care plan requires approval or authorization for specialist evaluation, radiological imaging studies or care in another medical facility, it is your responsibility to inform the office of this requirement prior to referral. We require 48 hours notice to facilitate a referral request, and we cannot issue retroactive referrals.
SELF PAY PATIENTS –Forest Park Family Medicine, Raintree Family Medicine and Richard L. Grandjean, M.D., P.A. recognize that some of our patients may be without insurance coverage, or may choose to receive care even when we are not “Participating Providers” with their managed care plan (“Out-Of-Network”). We do not believe in, nor do we endorse charging a fee greater than the fees we have agreed to receive from most managed care networks. Therefore, we have been instrumental in creating and developing the Jefferson Independence Card as a way for you to receive services at costs similar to the fees paid by many major managed care plans, in exchange for payment in full at the time of service. To learn more,and to obtain similar discounts on other healthcare services, please visit http://www.jeffersonicard.com.
OTHER SERVICES, CHARGES AND PATIENT RESPONSIBILITIES – Insurance policies generally do not include coverage for many administrative services, such as requests for medical records, prescription refills or after-hours medical consultation. The following services may be assigned an administrative services fee that will be billed directly to the patient. You are responsible for payment of these charges in full. Our practice is committed to providing the highest quality of service to our patients,while keeping our charges for administrative services at or below the usual and customary charges of other medical practices in the area. All such administrative fees must be paid prior to scheduling future appointments.
· Payment Plans – In cases where a payment plan has been accepted and agreed upon by the office manager, a $5.00 monthly charge will be added to the balance due until the account is paid in full
· Missed Appointments – Broken appointments represent not only a cost to us, but also reduce the available time we have to provide medical care to others who could have been seen in the time set aside for you. We require 24 hour notice of cancellation to avoid a $25-75 cancellation fee (depending on the type of appointment). While we strive to place a reminder call one or two business days before your appointment, it is your responsibility to remember your scheduled appointments.
· Prescription Refills (including controlled drugs) – New prescriptions will not be issued without first seeing Dr. Grandjean. Prescriptions for acute care or chronic conditions are usually written with an appropriate number of refills to complete the course of treatment or to last until your next scheduled appointment. These do not require further approval for refills. Consult your pharmacist as needed. Requests for medication changes will not be handled over the phone – the patient must see Dr. Grandjean. An administrative fee may be assessed if a refill is issued without the patient seeing the provider, a prescription is requested for mail-order, additional “extra” prescriptions are needed, or a pharmacy (or insurance plan) change is requested. Refill requests made during routine office hours will be charged $15 for 1 to 3 prescriptions and $25 for 4 or more medications. Requests for refills will be handled between 9:30 A.M. and 3:30 P.M., Monday through Friday. Any refill request received after 3:30 P.M.will be handled the next business day. Please allow up to 48 hours for prescription refills to be processed by your pharmacy.
· Prescription Authorizations – We will honor prior authorization requests. However, the patient will be responsible for contacting the insurance company or pharmacy benefit manager to have a prior authorization form sent to our office, and for asking what “alternative medications” are covered by their plan. There will be a $15 fee for completion of a prior authorization form.
· Form Completion – All forms requiring medical review and physician signature – including school, day care, and camp physicals, prior authorizations, Family Medical Leave Act (FMLA), disability or other paperwork – may be subject to a $15 administrative fee. Administrative fees may be waived if the patient has a scheduled appointment in conjunction with the form completion request.
· Health Care Advice – With the advent of the internet and other sources of health information, we find that we are consulted for health care advice, oftentimes not related to the patient’s current medical care or needs. Providing such information may require considerable thought and/or investigation on our part to coordinate with the patient’s exact medical condition. Therefore, any such advice – when unrelated to the patient’s current medical condition – may be subject to an administrative fee of $75 per quarter hour of investigation and response.
· After Hours Calls – All after hours calls for medical advice are subject to a $25 fee, which may be waived at the physician’s discretion. This fee will be billed directly to you, and it is your responsibility to remit payment in a timely manner.
· Requests for Medical Records – In accordance with Texas law, Richard L. Grandjean, M.D., P.A., Forest Park Family Medicine and Raintree Family Medicine, require a written and signed request for the release of medical records. The administrative fee is based upon guidance from the Texas Medical Board, $25 for the first twenty pages and $0.50 for each page thereafter. Both federal and Texas law grants the office up to 15 business days to process requests for records – Please take this into consideration when requesting copies of your records. Requests for expedited copies will be subject to an additional $25-100 fee, depending on the complexity of the records request. Research fees of $75 per quarter hour may be charged for complex record and/or billing requests. The office contracts record copying, release and transfer services to Lakeside Healthcare Strategies, LLC. All payments for medical record copying, release and transfer services should be made to Lakeside Healthcare Strategies, LLC.
Each time you visit or have contact with this office, a record of your contact/visit is prepared, which contains your Protected Health Information (PHI). We are required by law to maintain the confidentiality of health information which identifies you, and our entire staff is dedicated to this purpose. In addition, we must provide you with the following important information:
· How we may use and disclose your PHI;
· Your privacy rights regarding your PHI, and;
· Our obligations concerning the use and disclosure of your PHI.
The terms of this notice apply to all records containing your PHI, which 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 your records, past or future. We will post a copy of our current Notice in our office, and you may request a copy of the most current Notice at any time.
Use and Disclosure of PHI (We may use and disclose your PHI in the ways listed below):
· TREATMENT – We may use your PHI to provide, coordinate, or manage your healthcare and any related services. This includes providing your PHI to a third party, such as a pharmacy, a laboratory, ot a home health agency, for treatment purposes. We may also provide your PHI to another doctor or treatment facility involved in your care. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, parents, or home nurses.
· PAYMENT – We may use and disclose your PHI to obtain payment for the services which we provide. This includes disclosure to your insurance company to obtain information regarding eligibility and referrals, or whether a certain benefit is covered by your plan. In order to be reimbursed for treatment, we may need to disclose PHI by demonstrating the medical necessity of a service, as required by your insurance company. We may also disclose patient information to another provider for the other provider’s payment activities.
· HEALTH CARE OPERATIONS – We may use and disclose your PHI to operate this business, which may include quality assessment and improvement activities, employee review activities, compliance review and auditing, business management and general administrative activities, credentialing, and research.
· OTHER USES AND DISCLOSURES – As part of treatment, payment and operations we may also use or disclose your PHI to provide appointment reminders, to inform you of treatment options, and to inform you of health-related benefits or services which may interest you.
· USES AND DISCLOSURES BEYOND TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS – If requested to, we are permitted by law to disclose your PHI without your permission or authorization for a number of reasons, including, but not limited to: law enforcement activities, public health and safety concerns, requests by U.S. or foreign armed forces, national security, workers’ compensation, or if you are under the custody of a law enforcement official or you are an inmate. Other uses and disclosures of your PHI not permitted or required by law will be made only with your written authorization.
Except as otherwise provided by law, you have the right to:
· Receive a paper copy of this Notice of Privacy Practices. In certain circumstances, and with your permission, we may provide the copy to you electronically.
· Request, in writing, that this practice communicate with you about your health and related issues in a particular manner or location. The law dictates that we accommodate reasonable requests.
· Request, in writing, that this practice restrict our use or disclosure of your PHI for treatment, payment or health care operations. Your written request must describe in a clear and concise fashion the information you wish restricted and how you wish it to be restricted. We are not required to agree to your request.
· Request to inspect and/or receive a copy of your PHI, including medical records and billing records, but not including psychotherapy notes. Your request must be submitted in writing, and this practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. This practice may deny your request to inspect and/or copy in certain limited circumstances. However, you may request a review of our denial. Another licensed health care professional chosen by us, will conduct the review.
· Request that we amend your PHI if you believe it is incorrect or incomplete. Your written request must describe in a clear and concise fashion all information which supports your request for amendment. We may deny your request if you fail to submit it in writing, or if the request asks us to amend information which this practice feels in accurate and complete. We are not obligated to amend information which was not created by this practice or information which falls outside of the PHI category.
· Receive a list of certain non-routine disclosures our practice has made for purposes other than treatment, payment or healthcare operations. Requests for lists of non-routine disclosures must be made in writing.
· 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. Al complaints to this office must be filed in writing.
· Provide an authorization for other uses and disclosures. This practice will obtain your written authorization for uses and disclosures which are not identified by this Notice, or are permitted by applicable law.
Our contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Complaints and/or information regarding matters covered by this Notice can be requested by contacting Scott Grandjean at 214-327-3333. Requests in writing should be sent to:
Richard L. Grandjean, M.D., P.A.
Raintree Family Medicine
997 Raintree Circle, Suite 180
Allen, Texas 75013-4949
Attn: Privacy Officer
Call Us: (214) 327-3333
Richard L. Grandjean, M.D., P.A. - Board-Certified in Family Medicine
Raintree Family Medicine - Allen, Texas