支払い責任について
It is the policy of this office to collect payment for services as they are rendered. This allows us to control our costs and keep fees at a reasonable level. This office will assist in preparing forms for submission to your insurance company. However, the services cannot be rendered on the assumption that your charges will be paid in full by your insurance company. Accounts that are over 90 days will be subject to finance charges of 20% yearly. I, the undersigned, have read the above statement and accept full financial responsibility for all medical charges incurred for services rendered by Naoko Matsumoto, M.D., Inc.
Patient Partnership Plan 

患者パートナーシッププラン
- Schedule visits with my doctor for routine physical exams and other recommended health screenings I understand that my doctor will explain to me which regular health screenings are appropriate for my age, gender, and personal and family history. I understand I will need to complete these recommended health screenings (mammograms, immunizations, pap smears etc.) These health screenings are test that can help detect life-threatening diseases and conditions. If I visit my doctor only for treatment of immediate problems and forget to arrange for regular health screens, I put myself at risk of le􀆫ng serious health problems go undetected. I will schedule regular visits with my doctor to complete my physical exam and to discuss these health screenings.
- Keep follow-up appointments and reschedule missed appointments. I understand that my doctor will want to
know how my condition progresses after I leave the office. Returning to my doctor on time gives him or her the chance to check my condition and my response to treatment. During a follow -up appointment, my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious health condition. If I miss an appointment and don’t reschedule, I run the risk that my physician will not be able to detect and treat a serious health condition. I will make every effort to reschedule missed appointments as soon as possible. However, if I do not hear from my physician’s office within the time specified, I will call the office for my test results.
- I inform my doctor if I decide not to follow his or her recommended treatment plan, I understand that a􀅌er
examining me, my doctor may take certain recommendations based on what he or she feels is best for my health. This might include prescribing medica􀆟on, referring me to a specialist, ordering labs and tests, or even asking me to return to the office within a certain period of time. I understand that not following my treatment plan can have serious negative effects on my health. I will let my doctor know whenever I decide not to follow his or her recommendations so that he or she may fully inform me of any risks associated with my decision to delay or refuse treatment.
Thank you for your partnership. As our patient, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your health or condition, please ask.
Open Payments Database 

オープンペイメントデータベース
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
HIPAA Privacy Practices

(医療保険の相互運用性と説明責任に関する法律) 
Naoko Matsumoto, M.D. follows HIPAA guidelines in regard to your PHI (Protected Health Informa􀆟on). Copies of our Notice of Privacy Practices are available at the Front Desk. By signing below, you acknowledge that you have read and agree to our Privacy Practices.

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