Notice for request for paperwork/completion of forms

(i.e. Work letter, surgical clearance letter, FMLA, disability, handicap, etc.) 

FINANCIAL RESPONSIBILITY

Our office is pleased to assist you with your paperwork needs. It must be fully understood that the patient is entirely responsible for all applicable fees (per claim) which incudes but not limited to:

• $125 for initial paperwork request
• $100 for request of additional letter after submission of initial paperwork
• $75 for extension request after the initial paperwork
• $25 for medical record request
  

Office policy regarding Paperwork/form request:

1. Paperwork for the service request must be received in full ahead of date/time of your appointment. 
2. Except for medical record, patient must schedule a visit with the provider for the completion of paperwork. 
3. It is the patient responsibility to ensure that our office receive the details/forms  from your employer/agency/provider, our office will not contact your agent on your behalf. 
4. Our office does not guarantee approval of submitted claim. Our office will NOT enter into a dispute with your agent/agency/employer/company over a claim. This is your responsibility and obligation; our office is not obligated to continue to provide you with additional personal requests for information after submitting the initial agency required paperwork. 
5. No refund will  be issued after a clinical consultation has taken place. 
6. I understand and agree that I am responsible for all charges. I understand and agree to the policy.

NOTICE OF PRIVACY PRACTICES

Federal law sets rules for health care providers and health insurance companies about who can look at and receive our health information. This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it. You can ask to see or get a copy of your medical record and other health information.
If you want a copy, you may have to put your request in writing and pay for the cost of copying and mailing. You can ask to change any wrong information in your file or add information to your file if you think something is missing or incomplete. By law, your health information can be used and shared for specific reasons not directly related to your care, like making sure doctors give good care, reporting when the flu is in your area, or reporting as required by state or federal law. In many of these cases, you can find out who has seen your health information.
You can: Learn how your health information is used and shared by your doctor or health insurer. Generally, your health information cannot be used for purposes not directly related to your care without your permission.
For example, your doctor cannot give it to your employer without your written authorization.
Let your providers or health insurance companies know if there is information you do not want to share.
You can ask for other kinds of restrictions, but they do not always have to agree to do what you ask, particularly if it could affect your care.
Finally, you can also ask your health care provider not to tell your health insurance company about care you receive or drugs you take, if you pay for the care or drugs in full and the provider does not need to get paid by your insurance company.
Acknowledgement of Receipt of Notice of Privacy Practices The Notice of Privacy Practices is a complete description of my rights as a patient of SBHC.