Intake Form

DISCLOSURE ON THE IMPACT OF HEALTH CARE REFORM ON YOUR CARE

I hereby ACKNOWLEDGE that my doctor will make every attempt to deliver the best care possible in the context of the dynamically changing health care environment. where there is an increasing amount of regulation and rules as to appropriateness and medical necessity of procedures and surgeries.   In fact, your doctor is subject to such Medical Necessity and Appropriateness of Procedure Rules imposed by insurance companies, hospitals and surgery centers, where providers at the Center For Advanced Spine Care are currently performing procedures and surgeries at.   As a result, the treatment recommendation that your doctor/surgeon may make could be affected by these rules and may not be necessarily the most appropriate or preferred treatment in his or her clinical judgement.   In addition, procedures and surgeries may not be authorized and your doctor may simply not be able to perform them on you.  With the transition of our local health care system from a Clinical Guidelines based system to a Rules based system, your doctor may not be able to provide the preferred recommended care given those newly imposed constraints.

Office Financial Policies

Insurance: Our office verifies all insurance prior to your first appointment. The information obtained from your insurance carrier is not a guarantee of payment, it is only a review of the patient’s benefits. Upon our receipt of the insurance company’s claim payment, our office will address any discrepancies that arise due to incorrect information provided at the time of benefit verification. It is the patient’s responsibility to notify our office of any changes to the insurance prior to scheduling an appointment.

Referrals: Any referrals needed are the responsibility of the patient and must be presented before the scheduled appointment. Patients without a proper referral will be rescheduled to a later date.

Co-Pays: Co-pays are due at the time of service, any patient unable to pay at that time will be rescheduled to a later date.

Deductibles: Patients with large deductibles (over $2500.00) or large co-insurance will be required to pay a deposit of $150.00 at check in. The remaining balance and any lesser deductible amounts will be collected at check out based upon the insurance allowable. Patient credits will be applied to the next visit or refunded if no other appointments are necessary. All Refunds are by check and will be mailed Certified Return Receipt to the patient. Patients will large deductibles who are scheduling surgery will be required to pay their deductible before surgery.

Self Pay: All patients without insurance will be required to pay in full at check in. An initial evaluation fee is $450.00.

Forms of Payment: Our office accepts cash, checks (processed through E-Check), Mastercard and Visa. If a check is presented for payment and is not honored by the bank, the patient will be billed the bank charges and a $25.00 administration fee. If the issue is not addressed within 15 days the check will be forwarded to the Bad Check Program at the Pima County Attorney’s Office.

Automobile Insurance: Any incident involving an automobile accident must be filed with the patient’s automobile insurance. We do not billing automobile insurance. Patients with only automobile insurance will be considered a Self-Pay patient and will be responsible for all charges. The patient may then submit their own claim for reimbursment to their automobile insurance carrier.

Traveler’s Insurance and International Patients: Any international patients who have Canadian Health Care or Traveler’s Insurance will be considered self pay patients. The patient will be responsible for self pay charges at the time of service and will be responsible for submitting the claim to their insurance company.

Workman’s Compensation: If a patient is injured on the job it must be reported to the employer and approved before scheduling an appointment. The initial appointment is to be handled by the workman’s compensation adjuster and must be approved. If the employee is workman’s compensation exempt, a copy of the state exemption must be provided. Any non-participating worker’s compensation carrier will be required to sign our worker’s compensation agreement before making any appointments for the patient. The adjuster will be required to provide a translator for any non-English speaking patients.

Collections/Past Due Balances: Any patient with a past due balance will be required to make arrangements to settle their balance before they will be scheduled for an appointment. Any accounts being turned over to an outside collection agency will be assessed an administrative fee of 10% and a collection fee of 25% of the outstanding balance. This fee represents the cost of sending the account to collections, multiple invoicing, lost income, ect. The collection fee is what we will pay the collection agency to collect on the account.

Form Completion: Our office will complete FLMA and short term disability form within 14 days of receipt. The form completion prepayment per form is $30.00 due on receipt of the form. The patient must also sign a release of information before the form can be completed.

Medical Records: Patients requesting copies of their medical records must first sign a release. The charge is $1.00 per page for the first 30 pages and $0.50 for each additional page thereafter. There is a minimum charge of $30.00. Records can be picked up or mailed, they can not be faxed or emailed. Medical records requests take 10-14 days once the signed release is received.

Cancellations and No Shows: A $50.00 fee will be applied to any account (excluding AHCCCS) when the patient has not given at least 24 business hours notice of cancellation. AHCCCS patients, who can not be billed, will have their No Show reported to the AHCCCS plan.

Surgery Cancellations: Cancelled surgeries are a major drain on health resources to hospitals, surgery center and medical practices. Please be mindful of your scheduling needs when agreeing to a surgical date. Remember that a lot more goes into setting up your surgery than you picking a date. It costs money to make all the necessary services available to ensure that your surgery produces the excellent outcome you expect. For example, special procedures require specific implants and instrumentation to be ordered. The hospital may hire independent contractors for spinal cord and electrophysiological monitoring during your surgery. Other resources and manpower are set aside and earmarked for your scheduled surgery. Not showing up or cancelling your surgery on short notice presents significant problems not only to the hospital but also to us as it may impact our ability to schedule surgeries (including yours) in the future.

Therefore it is important that you make sure you pick your surgery date carefully. Patients who no show or cancel their surgeries with less than 24 hours will be charged a $500.00 fee for late cancellation and will be discharged from the practice. Patients who cancel their surgeries with less than 72 hours notice will be charged a $200.00 fee for late cancellation and may be discharged from the practice. Patients who cancel repeatedly may be discharged from the practice.

Dispute Resolution: I agree and consent to resolve any dispute(s) that may arise out of my medical treatment(s) by physicians at the Center for Advanced Spinal Surgery of Southern Arizona via mediation by filing a cast with the American Arbitration Association. I understand this does not apply to any billing or collections related disputes for services provided to me.

Assignment of Benefits

     I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other heath/medical plan, to issue payment check(s) directly to Kai-=Uwe Lewandrowski, MD and/or Center for Advanced Spinal Surgery, medical service rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information

     I hereby authorize Kai-Uwe Lewandrowski, MD and/or Cetner for Advanced Spinal Surgery to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.

     I have requested medical services from Kai-Uwe Lewandrowski, MD on behalf of myself and/or my dependants, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

     I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

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.

1. We Have a Legal Duty to Protect Health Information About You.

We at the Center for Advanced Spinal Surgery are committed to treating and using personal health information about you responsibly and with the utmost respect for your privacy. In addition to this moral and ethical obligation, there is also a legal obligation to do the same. We are required by law to protect the privacy of health information about you that can be identified with you, which we call “protected health information”, or “PHI” for short. We must give you notice of our legal duties and privacy practices concerning PHI:

• We must protect PHI that we have created or received about: your past, present, or future health condition; health care we provide to you; or payment for your health care.
• We must notify you about how we protect PHI about you.
• We must explain how, when and why we use and/or disclose PHI about you.
• We may only use and/or disclose PHI as we have described in this Notice.

This Notice describes the types of uses and disclosures that we may make and gives you some examples. In addition we may make other uses and disclosures, which occur as a byproduct of the permitted uses and disclosures described in this Notice. If we participate in an “organized health care arrangement” (defined in subsection B.3 below), the providers participation in the :organized health care arrangement” will share PHI with each other, as necessary to carry out treatment, payment or health care operations (defined below) relating to the organized health care arrangement”.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:

• Posting the revised notice in our office and on our website (tucsonspine.com); and
• Making copies of the revised notice available upon request.

1. We May Use and Disclose PHI About You Without Your Authorization in the Following Circumstances.
2. We may use and disclose PHI about you provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another provider.
3. We may use and disclose PHI about you to obtain payment for services.

Generally, we may use and give your medical information to others to bill and collect payment for the treatment and services provided to you by us or by another provider. Before you receive scheduled services, we may share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions of medical information about you with the following:

• A billing company:
• Collection departments and agencies, or attorneys assisting us with collections;
• Insurance companies, health plans and their agents which provide your coverage.;
• Hospital departments that review the care you receive to check that it and the costs associated with it were appropriate for your illness or injury; and
• Consumer reporting agencies (e.g. credit bureaus).

3. We may use and disclose PHI about you for health care operations.

We may use and disclose PHI in performing business activities, which we call “health care operations”. These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. We may also disclose PHI for the “health care operations” of any “organized health care arrangement” in which we participate. An example of an “organized health care arrangement” is the care provided by a hospital and the physicians who see patients at the hospital. In addition, we may disclose PHI about you for the “health care operations” of other providers involved in your care to improve the quality, efficiency and costs of their care or to evaluate and improve the performance of their providers. Examples of the way we may use or disclose PHI about you for “health care operations” including the following:

• Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients.
• Improving health care and lowering costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of people.
• Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
• Providing training programs for students, trainees, health care providers or non-health care professionals (for example, billing clerks or assistants, ect.) to help them practice or improve their skills.
• Cooperating with outside organizations that assess the quality of care we and others provide.
• Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty.
• Assisting various people who review our activities.
• Conducting business management and general administrative activities related to our organization and the services provided.
• Resolving grievances within our organization.
• Reviewing activities and using or disclosing PHI in the event that we sell our business, property or give control of our business or property to someone else.
• Complying with this Notice and with applicable laws.

4. We may use and disclose PHU under other circumstances without your authorization or an opportunity to agree of object.

We may use and/or disclose PHI about you for a number of circumstances in which you do not have consent, give authorization or otherwise have an opportunity to agree or object. These circumstances include:

• When the use and/or disclosure is required by law.
• When the use and/or disclosure is necessary for public health activities.
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for judicial and administrative proceedings.
• When the disclosure is for law enforcement purposes.
• When the use and/or disclosure relates to decedents.
• When the use and/or disclosure relates to organ, eye or tissue donation purposes.
• When the use and/or disclosure related to medical research.
• When the use and/or disclosure is to avert a serious threat to health or safety.
• When the use and/or disclosure relates to specialized government functions.
• When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations.

5. You can object to certain uses and disclosures.

Unless you object, we may use or disclose PHI about you in the following circumstances:

• As a patient in the hospital, your name, room number, and general condition (critical, serious, ect.) may be shared in the hospital’s directory with clergy and with people who ask for you by name.
• Using our best judgment, we may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care.
• We may share with a public or private agency (for example The American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency purposes.

If you would like to object to our use or disclosure of PHI about you in the above or other specific circumstances, please call or write our office using the contact information at the end of this notice.

6. We may contact you to provide appointment reminders or information.

We may use and/or disclose PHI to contact regarding an upcoming appointment you have for treatment or medical care.

7. We may contact you with information about treatment, services, products or health care providers.

We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value.

Any other Use or Disclosure of PHI About you Requires your Written Authorization

                    Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by our office. If you cancel your authorization in writing , we will not disclose PHI about you after we receive your cancellation, except for disclosures, which were being processed before we received your cancellation.

1. You Have Several Rights Regarding PHI About You
2. You have the right to request that we restrict the use and disclosure of PHI about you. We are not required to agree to your requested restrictions. However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection B.4 of the previous section of this Notice. You may request a restriction in writing at the address listed below.
3. You have the right to request different ways to communicate with you. You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number. Your request must be in writing. We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on you providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by writing to the address listed below.
4. You have the right to see and receive a copy of PHI about you. You have the right to request to see and receive a copy of PHI contained in clinical, billing, and other records used to make decisions about you. Your request must be in writing. We may charge you related fees. Instead of providing you with a full copy of PHI, we may give you a summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any right you may have to request a review of our denial. You may request to see and receive a copy of PHI by requesting this in writing at the address listed below.
5. You have the right to request amendment of PHI about you. You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record; 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copu the record as described in paragraph three above. We will tell you in writing the reasons for the denial and describe uour rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment. You may request an amendment of PHI by writing to the address listed below.
6. You have the right to a listing of disclosures we have made. If you ask us in writing, you have the right to receive a written list of certain disclosures of PHI about you. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003). We are required to provide a listing of all disclosures except for the following:

• For your treatment
• For billing and collection of payment for your treatment
• For health care operations
• Made to or requested by you, or that you authorize
• Occurring as a byproduct of permitted uses and disclosures
• Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in subsection B.5 above.
• Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (see subsection B.4 above) and
• As part of a limited set of information which does not contain certain information which would identify you.

This list will include the date of disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances. PHI about you has been disclosed for certain types of research projects, the list may include different type of information. If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by writing to the address listed below.

6. You have the right to a copy of this Notice

You have the right to request a paper copy of this Notice at any time by contacting our office. We will provide a copy of this Notice no later than the date you first receive service from us (except emergency services, and then we will provide the Notice to you as soon as possible.)

1. You May File a Complaint About Our Privacy Practices

If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, please contact us in the following manner:

Center for Advanced Spine Care of Southern Arizona
4787 E. Camp Lowell Drive
Tucson, AZ 85712
Fax: (623)218-1215

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

1. Effective Date of This Notice

This Notice of Privacy Practices is effective on August 29, 2013.

Revision of Notice of Privacy Practices

We reserve the right to change the terms of this notice, making any revisions applicable to all the protected health information we maintain. If we revise the terms of this notice, we will post a revised notice at the Center for Advanced Spinal Surgery, PLLC and will make paper copies of the revised Notice of Privacy Practices available upon request.