Healthcare Policy Procedures

HEALTHCARE POLICY PROCEDURES

Purpose: The purpose of these Healthcare Policy Procedures is to set forth the patient-facing administrative, clinical and privacy practices of the facility and to obtain the patient’s acknowledgement of receipt and consent where required.

Facility Details

Effective Date:    Revision Controlled: This document governs the operational expectations of staff and patients and supersedes prior patient-facing policy statements.

Patient Information

Emergency Contact

Insurance Information

Medical History (Patient-Reported)

Policy Statements and Procedures

Patient Rights and Responsibilities: Patients are entitled to respectful care, explanation of treatment, privacy and information about billing. Patients shall provide accurate information, follow care plans, and provide timely notice for cancellations. The facility reserves the right to terminate the provider-patient relationship consistent with applicable law.

Privacy and Confidentiality: The facility maintains administrative, technical and physical safeguards to protect protected health information. Use or disclosure of protected information for purposes other than treatment, payment or health care operations requires the patient’s written authorization except as permitted by law.

Consent for Treatment: By signing below, the patient authorizes the facility and its providers to perform diagnostic, therapeutic and ancillary services as clinically indicated. The patient has the right to refuse or withdraw consent to treatment at any time, subject to clinical counsel of treating providers.

Infection Control: The facility enforces standard precautions, employee immunization policies and visitor restrictions as necessary to protect patients and staff. Patients must comply with required screening and isolation instructions.

Medication Administration: Medications will be administered according to prescriber orders and facility policy. Patients must disclose all medications and supplements. Medication errors or concerns must be reported immediately to staff so they may be investigated and remediated.

Emergency Procedures: In an emergency, the facility will initiate life-saving measures and transfer to an acute care facility when clinically indicated. The facility may bill for emergency services in accordance with standard billing practices.

Billing and Financial Policies: Patients are responsible for charges not covered by insurance. Payment, co-payments and prior authorizations are to be made at or prior to the time of service when required. The facility may engage collection procedures for unpaid balances in accordance with applicable law.

Appointment and Cancellation: Patients are responsible for arriving on time and cancelling appointments with reasonable notice. Repeated no-shows or late cancellations may result in limited access to non-emergent services.

Grievance Procedure: Patients may submit complaints or grievances in writing to the facility’s patient relations office. The facility will investigate and provide a response within a reasonable timeframe.

Authorizations and Acknowledgments

Authorization to Release Information: I authorize the facility to release my health information to insurers, consulting providers and other entities for treatment, payment and health care operations as necessary. Recipient(s) for release (if specific):

Authorization Expiration Date: This authorization expires on or upon earlier revocation in writing.

Electronic Communications Consent: I consent to receive appointment reminders, billing statements and other communications via the following methods (check all that apply):

Email correspondence
SMS/text messages
Automated phone calls

Acknowledgment and Patient Certification

By signing below, I certify that I have received, read and understand the Healthcare Policy Procedures summarized above. I understand my rights and responsibilities as a patient and consent to the uses and disclosures of my protected health information described herein to the extent required for treatment, payment and health care operations.

I understand that I may revoke authorizations in writing except to the extent that the facility has already taken action in reliance thereon. I understand that refusal to sign an authorization for disclosure in certain circumstances may prevent the facility from obtaining payment or coordinating care with outside providers.

ACKNOWLEDGMENT: I acknowledge receipt of these Healthcare Policy Procedures and related privacy notice.

Patient Questions / Complaints

If you have concerns regarding these policies or care provided, please describe below. The facility will investigate and respond consistent with its grievance procedures.

Attestation

Attestation: I certify under penalty of law to the best of my knowledge that the information provided in this form is true and correct and that I am the patient named herein or an authorized representative with legal authority to sign on the patient’s behalf.

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