Arlington Family Health Pavilion Policies and Guidelines
The following is a list of guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible.
We are always pleased to be able to serve you as a physician under your insurance plan.
PLEASE READ ALL INFORMATION LISTED BELOW AND KEEP IN CONSIDERATION WHEN VISITING OUR OFFICE.
- We ask that you present you insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance.
- If you come to the office for a lab draw, you must present your card to the front desk so they can submit it to Quest Diagnostics for processing of your lab work. Quest Lab hours: Monday Through Thursday 8:00 a.m. to 12:00 p.m. and 1:30 p.m. to 4:30 p.m., and Friday 8:00 a.m. to 12:30 p.m.
- If you have a change of address, telephone numbers, or employer, please notify the receptionist.
- All deductibles, co-payments, co-insurance, or charge for non-covered services are due at the time of the office visit. If you have a balance after an insurance payment from a previous visit, we will also ask for that payment. Any payments made will be applied to the oldest balance existing on your account at the time.
- If we do not participate with your insurance company, you will be expected to make payment in full at the time service is rendered.
- We only accept existing Medicare patients at this time. We do not accept ANY work related injuries. We can refer you to a doctor that accepts work related cases.
- Motor vehicle accidents will have to be paid IN- FULL at time of visit. Insurance cannot be used if filing a claim with your/their car insurance.
- If your insurance denies our charges or does not pay us in a timely manner, or if your account becomes delinquent we reserve the right to refer your account to a collection agency and be to reported to the credit bureau.
- If you have a spouse that is a patient here and you both share an account together, any balance due is both parties’ responsibilities. Not one persons or the other. Any balances due will be expected to paid in full at the time of service.
- If you are a separated or a divorced family, and your child is a patient, please keep in mind that all co-pays/balances are due at the time services are rendered. We will not be involved in any personal disputes, or any court orders.
- MEDICARE PATIENTS: We are participating providers with Medicare and will bill Medicare for all your covered charges. If you have supplemental insurance, we will also bill that for you. If payment is not received from you supplemental insurance within 45 days of being submitted, we will bill you for the balance due. If you do not have a supplemental insurance, a portion (20% of amount allowed by Medicare) will be collected at the time of service. Each year you will be expected to pay the allowed amount of your charges until your Medicare deductible is met.
- All Medicare patients that either have a supplemental or secondary insurance: It is up to you to know which insurance is your primary and which is your secondary insurance. We do not know how your plans have been set up, nor do we have any access to that information do to HIPAA.
- HMO-PPO PATIENTS: If we participate with your plan, we will file your insurance for you. Your co-payment or deductible will be collected at the time of service no exceptions. If your plan requires you to choose a primary care physician, it is your responsibility to make sure your insurance company has the physician and/or Nurse Practitioner you are seeing in your office as your PCP. If your plan requires you to have an authorization to see a specialist, you still need to obtain that from our office prior to seeing the specialist. No retroactive referrals will be given. If we do not participate with you plan, we will verify your out-of-network benefits, file your charges, and will expect payment of your portion of the charges at the time of service. If we are not your primary care physicians, we will not be able to obtain an authorization to see a specialist or admit you to a hospital.
- SELF-PAY PATIENTS: Cash discounts will only be applied on the day of service. Patients with no insurance will be expected to pay IN FULL at the time of service. If you will not be able to pay in full, you must contact our billing department prior to seeing the doctor and/or Nurse Practitioner to make payment arrangements
- No-Show or Missed Appointments: When an appointment is scheduled with the doctor and/or nurse practitioner, time is specifically allocated for you. When an appointment is not canceled in advance, and the patient “no shows”, another patient that needed to be seen may have been unable to because the time slot was already taken. We understand there maybe times when you are unable to keep an appointment, but we ask the courtesy of a phone call to cancel an appointment by you. If two appointments are missed without cancellation, you may be charged a $30.00 fee. If three appointments are missed, you will be dismissed from the practice for non-compliance.
- Please be aware of your appointment time and try to arrive 10 minutes early if possible. Most of the time there is new paperwork or updated paperwork that might need to be addressed.
- If you are 15 minutes late or more you will either have to wait for the doctor/nurse to work you in around the other scheduled patients or may even have to reschedule for another day
- If you call for an appointment and the appointment scheduler placed you into a “work-in” appointment or will be “worked into” the doctors/nurse practitioners schedule, then please realize that there will most likely be a wait. This is a first come, first serve basis. This is also for ACUTE illness only. Please call before coming in so our staff can have your chart and paperwork ready for your arrival.
- TO ALL OUR PATIENTS: EFFECTIVE 10/1/2014
In compliance with new Federal Laws governing controlled substance, Nurse Practitioners and Physician Assistance are no longer allowed to prescribe or refill Hydrocodone or Hydrocodone combos in any form. These medications can only be filled by a prescribing MD. Please schedule follow up appointments accordingly.
If you take any Schedule II medications we will be charging a $5.00 fee for each prescription written. This will have to be paid at the time your prescription is picked up. This medication can no longer be called into your pharmacy.
Examples: Hydrocodone, Hydromet, Adderall, Vyvanse, Ritalin, Concerta, Oxycontin, etc.
Knowing Your Insurance
Your insurance is a contract between you, your employer, and the insurance company. It is very important that you understand the provisions of your policy. We cannot guarantee payment of all claims. If your insurance company pays only a portion of the bill or rejects your claim, any contact or explanation should be made to you, or the policyholder.
Reduction or rejection of your claim by your insurance does not relieve you of your financial obligation.
- We will do everything possible to make sure that the services we provide to you are covered by your plan; however, each policy is different and insurance companies DO NOT guarantee payment, even though you may have benefits. Please know that we only order testing or medications that we feel are medically necessary in your individual case; but insurance companies can make decisions about medical necessity within their company guidelines. Also, please understand that the employers can include or exclude items in the company policies when they contract with the insurance company.
- If you ever have any questions about insurance coverage, relating to the treatment you are receiving, please call your insurance company and ask them to explain your benefits to you.
Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges.
Phone Calls and Messages
- If you call to leave a message on any voice mail in the office, make sure that you state your date of birth and spell your full name. No nicknames please. The name that appears on your insurance card is what we will go by in our computer system and on your file.
- When leaving a message on a nurse’s voicemail, if the message is left after 2 p.m. then the message will not be answered until the following business day.
- When calling after hours, if it is an emergency, please call the answering service at 817-679-0054 and leave a message for them to relay the doctor/nurse on call.
- When requesting any refills, samples, paperwork, or general questions, please give us 24-48 hours for us to answer to your request. We respond to all requests in a timely manner and as quick as possible.
- We also have an email address that you can mail to at anytime: firstname.lastname@example.org
PHARMACEUTICAL Patient Assistance
Arlington Family Health Pavilion can assist you with your pharmaceutical patient assistance if needed if you do not have any insurance. We do charge some fees for assisting in getting your paperwork and future medications sent in. Please see the following prices if you would like us to assist you with this service.
- Yearly start up or renewal- $25.00
- Renewal within same year-$10.00
- Each prescription new or refill- $5.00
We hope this packet has given you useful information regarding how our office operates. Please feel free to ask any questions that you might have.
Arlington Family Health Pavilion, P.A.
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
In order to manage the care you receive, a record of your visit is created each time you visit any medical facility. AFHP understands that your medical information that is recorded or received about you and your health is personal. Federal and State laws protect the confidentiality of your health information. This Notice describes how AFHP may use and disclose you information and the rights that you have regarding your health information.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For examples, results of laboratory tests and procedures will be available in you medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, you health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Healthcare Operations. Your health information may be used as necessary to support the day-to-day activities and management of Arlington Family Health Pavillion. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
- Your information may also be released to collection agencies if payments are not received by the final notice date.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting.
Public Health Reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures that require your authorization
Unless you give notice of an objection, and in accordance with your Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Additional Uses of information
Appointment Reminders. Your health information will be used by our staff members to send you appointment reminders.
You have certain rights under the federal privacy standards. Theses include:
- The right to request restrictions on the use and disclosure of your protected health information
- The right to receive confidential communications concerning your medical condition and treatment
- The right to inspect and copy your protected health information
- The right to amend or submit corrections to your protected health information
- The right to receive an accounting of how and to whom your protected health information has been disclosed
- The right to receive a printed copy of this notice
Arlington Family Health Pavillion Duties
- We are required by law to maintain the privacy of your protected health information
- Provide you with a copy of the “Notice of Privacy practices”
- We also are required to abide by the privacy policies and practices that are currently in effect, and outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify out privacy policies and practices. These changes in our policies and practices may by required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
Requests to inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted federal regulation, we require that request to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to you records by contacting Michele, Kerri, or any of our office personnel. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
According to HIPAA guidelines our office has up to 30 days to issue the records you requested if your request was accepted. If for any reason we are unable to meet those requirements, we will submit to you a letter in writing explaining why we were unable to and when they will be available for you.
Be advised that our office is legally allowed and will most likely charge a copying fee of at least $25 per request per patient. This will vary upon the request.
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Arlington Family Health Pavillion, P.A.
707 N. Fielder Road, Suite A
Arlington, Texas 76012
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.
The name and address of the person you may contact for further information concerning our privacy practices is:
Arlington Family Health Pavillion, P.A.
707 D. Fielder Road, Suite A
Arlington, Texas 76012
Effective Date: This notice is effective on after 09/01/2008