We would like to thank you for choosing The Health Associates of Tampa as your primary care provider. We are committed to provide our patients with high quality medical care in a cost effective manner. To accomplish this, we depend on receiving prompt payment for our services. To keep you informed of our current office and financial policies, we ask that you read and sign our financial acknowledgement prior to any treatment. Please keep this document for future reference.
Cancelled Appointments: If you are unable to keep your scheduled appointment, please call our office within 24 hours to reschedule. This will enable us time to use your slot for another patient. We reserve the right to charge a fee of $25 for appointments cancelled or broken without 24 hours notice.
Payment: The Health Associates of Tampa provides a variety of payment methods. We accept cash, checks, Visa and MasterCard. For patients with no medical insurance: Payment will be due at the time of service. If you are unable to pay your balance in full you will need to make prior arrangements with our Billing Office. Patients with Medical Insurance: Please bring your insurance card with you at the time of your appointment. For insurance plans that we contract with, your carrier requires that all co-pays be paid prior to any services being rendered. The copay requirement cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier. If you do not have your co-pay at the time of your visit, a processing fee will be added to your account to cover additional billing expenses that will be incurred .
You are responsible for any co-insurance, deductibles or non-covered services as required by your insurance. You will receive a statement from our office indicating what your insurance has paid. Any remaining balance is due upon receipt of that statement. Any balance over 60 days will be assessed a late fee. A payment plan can be arranged with our Billing Department upon request.
Patients are responsible for knowing the benefits covered by their insurance policies. Our services are documented to comply with federal law and will be billed accordingly. Verification that our providers are “in network” with an insurance plan is the patient’s responsibility. Patients are responsible for verification that all referrals or prior authorizations are attained before services are provided, as imposed by their benefit plan.
Auto Accident Injury: If your injury is due to an automobile accident, we require that you provide us with any information that will assist us in getting your medical claims paid. You must contact the office and a form with the information required will be made available for you to complete.
Payment for any services that we provide will ultimately be your responsibility if not paid promptly by another party.
Liability Injury: If your injury is a result from another party’s negligence, we request that you provide us with any information that will assist us in obtaining reimbursement for the services rendered to you. You must contact the office and a form with the information required will be made available for you to complete. Payment for any services that we provide will ultimately be your responsibility if not paid promptly by another party.
Worker’s Compensation: If your injury is due to an accident in your work place, please be sure to contact your employer and inform them of your injury. We will need to receive authorization from your employer before we can process any of your medical claims. Please have your employer contact our Billing Department at 813-877-6770. Failure to properly report this injury to your employer may result in your claims being denied. Denied claims will be your responsibility.
Returned Checks: A $31.00 charge will be added to your account for any check returned by your bank for any reason. This is subject to change based on bank charges.
Medical and Other Forms: There will be a charge of $15.00-$35.00 for the completion of forms such as school physical, school sports, employment, adoption, fitness center, etc. (charge is based upon number of pages and complexity of information requested). Payment is due when you pick up the forms. Please allow 7-10 days for the completion of these forms. If you would like the forms mailed, payment will be due prior to mailing and will include postage costs. (There is no charge for Disability Forms)
Medical Records: We will provide you with a copy of your medical records upon request. You will need to sign a letter of release at the time of pick-up. Please allow 7-10 days for us to copy your records. There is a minimal fee for records based on the number of copies. If you wish for your records to be mailed there will also be an additional fee for postage. Rates charged are within Florida State limits.
I acknowledge full financial responsibility for services rendered by The Health Associates of Tampa. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including coinsurance, deductibles and co-pays. I understand payment of co-pays is expected at time of service, as well as any prior balance I may owe. I also consent that the payment of authorized Medicare insurance benefits be made on my behalf directly to The Health Associates of Tampa for any medical services furnished. I agree to all reasonable attorney fees and collection costs in the event of default of payment of my charges as outlined in office and financial policies guidelines. I acknowledge that I have received a copy of the office policies.
For a more detailed description of this consent and other uses and disclosures please review our Notice of Privacy Practices. I understand that The Health Associates of Tampa reserves the right to change its privacy practices that are described in the Notice. I also understand that any Revised Notice will be posted on The Health Associates of Tampa’s website and will be posted at the office.
I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so. I also understand that I will not be able to revoke this consent in cases where the physician has already relied upon it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office.
THE HEALTH ASSOCIATES OF TAMPA BAY, P.A.
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Revised as of July 31, 2016
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.
If you have any questions or wish to receive additional information about the matters covered by this Notice of Privacy Practices (“Notice”), please contact the Privacy Officer for THE HEALTH ASSOCIATES OF TAMPA BAY, P.A. (“THAT”), Jeetpaul Saran, M.D. at 608 S. Tampania Ave., Tampa, FL 33609 or call: (813) 877-6770.
This Notice is provided to you in compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act, Title XIII of the American Recovery and Reinvestment Act of 2009 (the “HITECH Act”) and associated regulations, as may be amended (collectively referred to as “HIPAA”) describing THAT’s legal duties and privacy practices with respect to your Protected Health Information (“PHI”). THAT is required to abide by the terms of this Notice currently in effect, and may need to revise the Notice from time to time. Any required revisions of this Notice will be effective for all PHI that THAT maintains. A current copy of the Notice will be posted in each office and you may request a paper, or electronic, copy of it.
PHI consists of all individually identifiable information which is created or received by THAT and which relates to your past, present or future physical or mental health condition, the provision of health care to you, or the past, present or future payment for health care provided to you.
HIPAA permits THAT to use or disclose your PHI in certain circumstances, which are described below, without your authorization. However, Florida law may not permit the same disclosures. THAT will comply with whichever law is stricter.
15. If you do not object to the following uses or disclosures of your PHI, THAT may: 1) disclose to a family member, other relative, a close personal friend, or other person identified by you the information relevant to their involvement in your care or payment related to your care; 2) notify others, or assist in the notification, of your location, general condition, or death; or 3) disclose your PHI to assist in disaster relief efforts.
16. Any use or disclosure of your PHI that is not listed herein will be made only with your written authorization. You have the right to revoke such authorization at any time, provided that the revocation is in writing, except to the extent that: 1) THAT has taken action in reliance on the prior authorization; or 2) If the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
To request that THAT make communications of your PHI by alternative means or at alternative locations, please send a written request to the Privacy Officer setting forth the alternative means by which you wish to receive communications or the alternative location at which you with to receive such communications. THAT will not ask why you are making such a request.
If you wish to inspect or obtain a copy of your PHI, please send a written request to the Privacy Officer. If you request a copy of your PHI, THAT may charge a fee for the cost of copying and mailing the information. You may also request that a copy of your PHI be transmitted to you electronically.
HIPAA permits THAT to deny your request to inspect or obtain a copy of your PHI for certain limited reasons. If access is denied, you may be entitled to a review of that denial. If you receive an access denial and want a review, please contact the Privacy Officer. The Privacy Officer will designate a licensed health care professional to review your request. This reviewing health care professional will not have participated in the original decision to deny your request. THAT will comply with the decision of the reviewing health care professional.
To request an accounting of the disclosures of your PHI, please send a written request to the Privacy Officer. Your written request must set forth the period for which you wish to receive an accounting. THAT will provide one free accounting during each twelve (12) month period. If you request additional accountings during the same twelve (12) month period, you may be charged for all costs incurred in preparing and providing that accounting. THAT will inform you of the fee for each accounting in advance and will allow you to modify or withdraw your request in order to reduce or avoid the fee.
If you believe that your privacy rights have been violated, you may file a complaint with THAT or with the Secretary of Health and Human Services. To file a complaint with THAT, please contact the Privacy Officer at the address listed on page 1 of this notice. All complaints must be submitted in writing. THAT WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.
Revised as of July 31, 2013
By law, we are required to make available to you a copy of our Notice of Privacy Practices (“Notice”). By signing below you acknowledge that you received, or been offered and declined, a copy the Notice.
A current copy of the Notice is also posted in the office, or is available to you upon request. If the Notice is revised, you may review and obtain the new version at any time.
You may decline to sign this acknowledgement.
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