Our goal is to maintain a good physician-patient relationship. Knowing our office policy in advance enables good flow of communication and allows us to achieve our goal. Please read this carefully and if you have any questions, please do not hesitate to ask a member of our staff.
We will require all of your insurance information before providing medical services, including a copy of your current insurance card. Some insurance policies require prior authorization before we can see you.
Please understand that our relationship is with you, not your insurance company, therefore if we do not have all the necessary insurance information, we will be unable to bill your insurance company and you may be responsible for the total charge at the time of your visit. If you have any questions regarding your insurance coverage prior to your visit, please call your insurance company. Patients/guarantor are ultimately responsible for knowledge of specific coverage guidelines and requirements pertaining to the patient's insurance plan.
If you do not have insurance, please contact our business office for information regarding payment options.
It is our policy to collect payment of co-pays, deductibles, and deposits for services rendered at the time you check in for your office visit. The patient/guarantor assumes responsibility for all unpaid balances, co-payments, and deductibles due, as well as any non-covered service by the insurance company, including cost of collection.
We accept payments by cash, check, money order and credit card (VISA, MasterCard, or Discover).
We DO NOT file auto insurance or health insurance related to motor vehicle accidents. It is our policy that payment be made in full at the time services are rendered and the patient/guarantor will seek reimbursement from the responsible insurance. We will provide a copy of the receipt upon request for your reimbursement.
If your visit requires lab tests, x-rays or any other services done outside of our office, these services will be billed to you directly by those providers. We will give these providers all your insurance information.
Our office staff is always willing and available to discuss billing matters with you at any time.
This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical and personal information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please call our office.
1. How this medical practice may use or disclose your health information:
This medical practice collects health information about you and stores it in a computerized medical record. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes.
a. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services which we do not provide. We may share this information with a pharmacist who needs it to dispense a prescription to you or to a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured.
b. Payment. We use and disclose medical information about you to obtain payment for services we provide. For example, we give requested information to your health plan(s) in order to facilitate reimbursements. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
c. Health care operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. We may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical review, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates", such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contain terms requiring them to protect the confidentiality and security of your medical information. Although federal law does not protect health information which is disclosed to someone other than another health care provider, health plan or health care clearinghouse, under Utah law all recipients of health care information are prohibited from re-disclosing it except as specifically required or permitted by law. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their efforts to improve health or reduce health care costs, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.
d. Appointment reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
e. Notification and communication with family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family members.
f. Required by law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
g. Public health. We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medication; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
h. Health oversight activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspection, licensure and other proceedings, subject to the limitations imposed by federal and Utah law.
i. Judicial and administrative proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
j. Law enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
k. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.
l. Public safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
m. Specialized government functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
n. Workers' compensation. We may disclose your health information as necessary to comply with workers' compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.
o. Change of ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
p. Breach notification. In the case of a breach of unsecured health information, we will notify you as required by law. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.
2. When this medical practice may not use or disclose your health information:
Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
3. Your health information rights:
a. Right to request special privacy protections. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.
b. Right to request confidential communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
c. Right to inspect and copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee for copy service, as allowed by Utah and federal law. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have the right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional. If your written request clearly, conspicuously and specifically asks us to send you or some other person or entity an electronic copy of your medical record, and we do not deny the request as discussed above, we will send a copy of the electronic health records as you requested, and will charge you no more than what it cost us to respond to your request.
d. Right to amend or supplement. You have the right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.
e. Right to an accounting of disclosures. You have the right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in the paragraphs related to treatment, payment, health care operations, notification and communication with family and specialized government functions in Section 1 of this Notice of Privacy Practices or disclosures for purposes of public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
f. You have the right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by email.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our office.
4. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area and a copy will be available at teach appointment.
Complaints about this Notice of Privacy Practices on how this medical practice handles your health information should be directed to our office.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
The Office for Civil Rights
Department of Health and Human Services
Room 1426, Federal Office Building
1961 Stout Street
Denver, CO 80294
Telephone: 303-844-2024/TDY 303-844-3439
The complaint form may be found at You will not be penalized for filing a complaint.