Patient Forms

Franktown Family Medicine
Thank you for choosing Franktown Family Medicine as your primary care health provider. We are committed to providing quality health care to you. Please understand that payment of your bill is considered part of our professional relationship. The following is a statement of our Financial Policy, which we require you to read and sign prior to treatment.

Time of Service Fee Schedule:
The time of service (TOS) fee schedule applies to our standard fee schedule within the office. The TOS fee schedule is available to all, including patients and insurance carriers. Pre-payments or payments made at the time of service (check, cash, credit card) receive a substantial cost savings due to reduced practice overhead expenses and claims processing, collecting and follow-up.

Regarding Insurance:
We will do our best to verify your insurance coverage. However, please be aware that your insurance company will not guarantee benefits over the telephone. They will give an explanation of benefits, but actual benefits are determined when the claim is received by your insurance company. Please be aware that some and perhaps all of the services provided may be non-covered services and may not be considered reasonable and necessary under Medicare and/or other medical insurance.

You are ultimately responsible for understanding your policy and the coverage your insurance company provides. You are also responsible for any unpaid insurance claims. Payment is expected upon notification from your insurance company that a claim was denied, applied to a deductible, or not covered under your plan.

You are also responsible for any portion of your bill that your insurer does not pay for (except managed care fees that are stipulated in your insurance policy).

You may have a deductible that needs to be met before your insurance company covers charges. A deductible is the amount you must pay out-of-pocket before your insurance company pays any benefits. Payment is due for your deductible at the time of service.

After your deductible has been met, you may still have a co-payment due on each visit. Payment for your co-payment is due at the time service is provided.

We will bill your insurance company for all applicable charges. Supplements are generally not a covered expense.

If your insurance company is not one that we are contracted with, full payment is expected at the time of service. We will be happy to provide you with a receipt that you may submit to your insurance company.

If you are insured through an HMO provider, you are responsible for obtaining a referral before your visit. If you need assistance with this, please call our office before your visit.

Regarding Acupuncture / Physical Medicine:
It is possible that these services are covered benefits under your current insurance plan. However, we are not contracted with most insurance companies to provide these services. We will bill acupuncture and physical medicine service to your insurance company only if a) we are contracted with your insurance company to provide these services, b) these are covered benefits as part of your insurance plan and, c) the appropriate verification of coverage and authorization is obtained. If these services are not covered by your insurance plan, or if we are not contracted with your insurance company, full payment is expected at the time of service.

I have read and understand the foregoing financial policy.

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Patient Signature / Date

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Office Staff Signature / Date
 

FRANKTOWN FAMILY MEDICINE
PO BOX 11, Franktown, Colorado, 80116
(303) 688-1111

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to that information. Please review this notice carefully.

Franktown Family Medicine (FFM) in accordance with federal Privacy Rule, 45 CFR parts 160 and 164 (the “Privacy Rule”) and applicable state law, is committed to maintaining the privacy of your protected health information (PHI). PHI includes information about your health condition and the care and treatment you receive from FFM and is generally referred to as your health care or medical record. This Notice explains how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.

How FFM May Use and Disclose your Protected Health Information

1. Treatment – To provide you with the health care you require, FFM may provide your PHI to those health care professionals, whether on our staff or not, so that we may provide, coordinate, plan and manage your health care. For example, if we are treating you for lower back pain, we may need to know and obtain results of your latest physician exam, last treatment, x-rays, etc.
2. Payment – To get paid for services provided to you, FFM may provide your PHI, directly or through a billing service, to a third party who may be responsible for your care, including insurance companies and health plans. If necessary, FFM may use your PHI in other collection efforts with respect to all persons who may be liable to FFM for bills related to your care. For example, FFM may need to provide your health insurance carrier with information about services rendered to you to facilitate payment of your claims. FFM may also need to inform your insurance carrier regarding planned treatment to determine whether or not it will be a covered expense.

Other Examples of How FFM May Use Your Protected Health Information
1.FFM may disclose to a family member, other relative, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care. However, the following conditions will apply:

• 2. If you are present at or prior to the use of disclosure of your PHI,FFM may use or disclose your PHI if you agree, or if FFM can reasonably infer from the circumstances, based on our professional discretion, that you do not object to the use or disclosure.
• 1.If you are not present, FFM will, at our professional discretion, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is relevant to the person’s involvement with your care.

Other Use & Disclosures Which May Be Permitted or Required by Law
FFM may also use and disclose your PHI, without your consent or authorization for the following circumstances:

• Un-identified Information – FFM may use and disclose health information that does not contain any identifying personal information about you.
• Business Associate – FFM may use and disclose PHI to its business associates if IMCC obtains written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is any entity that assists FFM in accomplishing some essential function, such as a billing service that is involved in submitting claims for payment to insurance companies.
• Personal Representative – Any person who, under applicable law, has the authority to represent you in making decisions related to your health care.
• Emergency Situations – For the purpose of obtaining or rendering emergency treatment to you provided that FFM attempts to obtain your consent as soon as possible; or to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care in an emergency situation.
• Public Health Activities – PHI may be disclosed when required by law to provide information to a public health authority to prevent or control disease.
• Abuse, Neglect or Domestic Violence – PHI may be disclosed when required by law to provide information if it is believed that the disclosure is necessary to prevent serious harm.
• Health Oversight Activities – When required by law to provide information in criminal investigations, disciplinary actions, or other activities relating to the community’s health care system.
• Judicial and Administrative Proceeding – In response to a court order or a lawfully issued subpoena.
• Law Enforcement Purposes – To a law enforcement official, when authorized. For example, if your PHI was required due to a grand jury subpoena, or if death was the result of criminal conduct.
• Coroner or Medical Examiner – For purposes of identification or determination of cause of death.
• Organ, Eye or Tissue Donation – To the entity whom you have agreed to donate your organs, if you are an organ donor.
• Avert a Threat to Health or Safety – Based on our professional discretion, if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and, the disclosure is to a person who is reasonably able to prevent or minimize the threat.
• Specialized Government Functions – When authorized by law with regard to certain veteran or military activity.
• Workers’ Compensation – To an individual or entity that is part of the Workers’ Compensation system if you are involved in a workers’ compensation claim.
• National Security and Intelligence Activities – To authorized government officials with necessary intelligence information for national security activities.
• Military and Veterans – As required by the military command authorities if you are a member of the armed forces.

Authorization
Uses and/or disclosures, other than those described, will be made only with your written authorization.

Your Rights
You have the right to:

• Revoke your authorization or consent you have given to FFM, at any time. To request a revocation, you must submit a written request to FFM’s Privacy Officer.
• Request special restrictions on certain uses and disclosures of your PHI as authorized by law. In general, this relates to your right to request special restrictions concerning disclosures of your PHI regarding uses for treatment, payment and operational purposes under Privacy Rule Section 164.522(a) and restrictions related to disclosures to your families and other individuals involved in your care under Section 164.510(b). Except in certain instances, FFM may not be obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to FFM’s Privacy Officer, informing FFM what information you want to limit, whether you want to limit FFM’s use or disclosure, or both, and to whom you want the limits to apply. If we agree to your request, FFM will comply with your request unless the information is needed in order to provide you with emergency treatment.
• Receive confidential information or PHI by alternative means or at alternative locations as provided by Privacy Rule Section 164.522(b). For example, you may request all written communications to you be marked “Confidential Protected Health Information”. You must make your request in writing the FFM’s Privacy Officer. We will accommodate all reasonable requests.
• Inspect and copy your PHI as provided by federal law (including Section 164.524) and state law. If you wish to inspect and/or copy your PHI, a written request is required to be submitted to FFM’s Privacy Officer. We may charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are
• defined by law, we may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.
• Amend your PHI as provided by federal law (including Section 164.526)and state law. A request to amend your PHI must be submitted in writing to FFM’s Privacy Officer. You must provide a reason that supports your request. We may deny your request if it is not in writing, if you do not provide a reason to support your request for an amendment, if the information to be amended was not created by FFM (unless the person/entity that created the information is no longer available), if the information is not a part of your PHI maintained by FFM, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with our denial, you have the right to submit a written statement of disagreement.
• Receive an accounting of disclosures of your PHI as provided by federal law (including Privacy Rule Section 164.528) and state law. A written request submitted to FFM’s Privacy Officer is required for an accounting of disclosures of your PMI. Your request must indicate a time period, which may not be longer than six (6) years and may not include dates before April 14, 2010. Your request should indicate whether a paper or electronic response is requested. The first list you request within a twelve (12) month period will be free of charge, but additional requests will be provided for a fee. We will notify you of the cost involved and you can decide to withdraw or modify your request before any costs are incurred.

• Receive an additional copy of this Privacy Notice from FFM (as provided by Privacy Rule Section 164.520(b)(1)(iv)(F)) upon request to FFM’s Privacy Officer.
• Complain to FFM (as provided by Privacy Rule Section 164.520(b)(1)(vi)) if you believe your privacy rights have been violated. To file a complaint, you must contact FFM Privacy Officer. All complaints must be in writing.

To obtain more information about your privacy rights or if you have questions you would like answered about your privacy rights (as provided by Privacy Rule Section 164.520(b)(2)(vii)), you may contact FFM’s Privacy Officer, as follows:

Name: Denise Christensen
Address: PO Box 894, Franktown, Colorado, 80116
Telephone: (303) 688-1111

FFM’s Requirements
FFM:

• Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing our legal duties and privacy practices with respect to your PHI
• May be required by State law to maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.
• Is required to abide by the terms of this Privacy Notice.
• Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
• Will provide you a copy of any revised Privacy Notice prior to implementation
• Will not retaliate against you for filing a complaint.

Effective Date
This Notice is effective as of 4/14/2010.

Patient Acknowledgement
I acknowledge receipt of a copy of this Notice, and agree and understand to its terms.

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Date

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Signature
Name :

FOR FFM USE ONLY

FFM Documentation of Good Faith Effort to Obtain Acknowledgment
Patient’s acknowledgment of this Notice could not be obtained because of the following:

• Patient refused to sign
• Communication barrier prohibited obtaining acknowledgment
• Emergency circumstances
• Other

Details:

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FFM Staff Signature

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Dated:

Notice of Privacy Practices

The Notice of Privacy Practices (NPP) is FFM’s fundamental privacy document. The requirements of its preparation and use are detailed in the Privacy Rule, Section 164.520.

A proper NPP will inform our patients of all the basic uses FFM will make of a patient’s Protected Health Information (PHI) in the ordinary course of treatment, various activities of FFM staff to obtain payment or be reimbursed for services rendered, and FFM’s general health care operations (TPO; treatment, payment, operations). The NPP will also advise the patient of other circumstances in which their PHI might be released, such as to comply with court orders, subpoenas and government investigations.

The NPP advises patients of their rights:

1. to revoke any authorization or consent they may have given to FFM to authorize disclosures of their PHI (usually for non-TPO purposes),
2. to request special limits or conditions on the use of their PHI,
3. to receive correspondence from FFM by more confidential means or at alternate locations,
4. to inspect and/or copy their PHI, and
5. to amend their PHI.

This NPP should be acknowledged by all patients receiving service after the compliance date for the Privacy Rule of April 14, 2003.

FFM must make a good faith effort to obtain the patient’s acknowledgement of receipt of the NPP. If the patient is unable or unwilling to acknowledge receipt of the NPP, FFM must document our attempt to obtain this acknowledgement in the patients’ chart.

The NPP must be conspicuously posted in our offices. Additional copies of our NPP will be made available to patients upon their request.

In the event the NPP is revised, the revised NPP must be posted and patients must be provided with a copy of the new and revised NPP.

FRANKTOWN FAMILY MEDICINE, LLC

General Consent: I consent to evaluation and treatment. I understand that multiple treatment options exist, with varied risks and benefits, including drugs and surgery. I may choose not to receive treatment. If the risks and benefits of a proposed treatment/intervention are not clear, further information may be requested by me. I give full consent to receiving treatment, understanding that there are potential risks. Information within the patient chart is confidential. I understand that all requests for release of my records must be in writing and signed by me. I understand that I have a responsibility to communicate honestly to the Franktown Family Medicine health care team and notify them of any changes in my health status. If my condition is determined to be medically complex, or felt could benefit with physician management, with the primary goal of improving clinical outcomes and efficacy, I give full and unconditional consent that Franktown Family Medicine, LLC manage, supervise or delegate care and bill me or my insurance for professional services.

Financial Consent: I understand I am financially responsible for all charges incurred by me, whether or not my insurance pays. I assign my insurance benefits to Franktown Family Medicine. Any overpayment will be promptly refunded. I authorize Franktown Family Medicine/ to release protected health information to secure payment. Accounts over 90 days past due are subject to a monthly finance charge of 1.5%, 18% annually and collection costs.

Release of Records: I authorize _______________________ to release all health records necessary for my treatment and/or evaluation to Franktown Family Medicine

Patient Signature __________________________________________________ Date ____/____/_____
Responsible Part’s Signature (If patient is a minor)_______________________ Date ___ /_____/_____