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FINANCIAL POLICY

You are responsible for copayments, deductibles and coinsurance as directed by your insurance policy and payment is expected at the time of service. For your convenience, we accept cash, checks, Visa/MasterCard, Discover, American Express and convenient monthly payment plans from Care Credit. If treatment is discontinued after payment has been received, you may receive a refund less the cost of care received. Failure to pay at the time of service may result in your appointment being rescheduled.

Insurance

For your convenience, we will file insurance claims with all insurance carriers. You will be responsible for any deductibles and coinsurance as explained in your policy. We cannot bill your insurance company unless you provide us with all insurance information, so please bring your insurance cards to your appointment. You are responsible for notifying us of any changes in insurance coverage each visit. If no insurance card is presented at the time of service, you will be treated as a cash patient and will need to pay for services as they are rendered. Once the card is presented within our insurance contract guidelines for billing claims and your carrier does not require prior authorization, we will gladly file a claim and refund any money due back to you after claims have been processed and we receive payment from insurance.

Out-of-Network or Non-Covered Services

 If patient is out of network due to our doctor(s) not yet contracted but is in processing, we will consider patient as in network and will use in network rates to balance bill patients. Charges that are not covered by your carrier, we may bill you and payment is due upon receipt.

Private Pay

If you do not have insurance, payment is due at time of service. We accept cash and credit cards. Please be prepared to pay in full at the time of your visit unless prior payment arrangements have been made.

Payment Plan/Arrangements

Payment plans are available and are based on account balances. The balance on the account should be paid in full within 3-12 months depending on your account balance and meeting minimum payment requirements. Monthly payments are expected on your account. Failure to pay monthly on your account may result in collection efforts that may result in being discharged from the practice. Please contact our billing department immediately for further information.

Worker’s Compensation

Only authorized referrals will be accepted. If notification is not received prior to the appointment, the patient will be responsible for charges incurred. Patient must notify Tulsa Pain Consultants Consultants prior to their scheduled appointment with the following information: attorney’s name and phone number; employer name, contact person and phone number; work comp carrier name, adjustors name and phone number; the date of injury, and claim number. Any court order must be brought in at time of visit. If work comp denies your treatment, we cannot bill your insurance company and your account will be private pay. Payment will be required at the time of service.

Personal Injuries/ MVA

Payment is expected at time of service. We will file private insurance provided you have subrogated with your insurance company. The patient is responsible for all copays and they are due at time of service. Deductible and/or coinsurance are the patient’s responsibility and are required to be paid when billed. We will accept Med-Pay if available provided said Med-Pay will issue direct payment to Tulsa Pain Consultants Consultants.

Returned/Insufficient Checks

If we receive your check back from the bank for insufficient funds/account closed, you may receive a $25 charge to your account and we will no longer accepts any checks for your account. You may pay on your account by cash, credit card or money order.

Testing:

If your insurance requires urine drug testing to be performed outside our office. You may receive an additional bill from this laboratory. If you have any questions regarding these bills, please contact the laboratory directly for billing questions.

No Show appointments:

If you fail to reschedule or cancel an appointment a $30.00 fee may be applied to your account.

NOTICE OF PRIVACY PRACTICES

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Effective date April 14, 2003

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.

Tulsa Pain Consultants Consultants (including its family of clinics) is committed to protecting your medical information. This Notice describes your rights and our legal duties regarding your protected health information. We create and maintain, on a variety of media, including paper, computers and films, a record of the care and services you receive. This information is available to all Office Practice employees, and physicians, who need this information to provide treatment to you, to obtain payment for services rendered to you or to support health care operations necessary for the operational aspects of your care. We are required by law to:

  • Have proper safeguards in place to discourage improper use or
  • Protect the privacy and confidentiality of your personal and protected health information and
  • Describe your rights and our legal duties regarding your protected health

WHAT DO THESE WORDS MEAN?

Protected Health Information (PHI)

Your personal and protected health information created and used by us to provide care to you and bill for services provided.

Privacy Officer

The person responsible for the policies and procedures developed to protect your PHI and for investigating your complaints on how your PHI is used or disclosed.

Business Associate

An independent business or individual who contracts with the Office Practice for services provided to you or the Office Practice.

Authorization

A document signed by you that gives us permission to use or disclose your protected health information for purposes other than your treatment, obtaining payment for your treatment or our health care operations.

WHAT WILL YOU DO WITH MY MEDICAL AND BILLING INFORMATION?

The following categories describe how we may use and disclose your protected health information. Not every use or disclosure in a category will be listed. To ensure compliance with Oklahoma law, we will obtain your consent for the use and disclosure of your protected health information. INFORMATION USED AND DISCLOSED MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE AND MAY INCLUDE, BUT ARE NOT LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA AND THE HUMAN IMMUNO-DEFICIENCY VIRUS ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY

SYNDROME (AIDS). If you do not consent, we cannot provide you treatment except in emergency situations or when we cannot communicate with you for some other reason.

  1. Treatment: We may use your protected health information to provide you with medical treatment or services. We may disclose your protected health information to doctors, nurses, technicians, medical students, or other Office Practice personnel who are involved in your

Example:

  • The surgeon treating your broken leg may need to know if you have diabetes because diabetes may slow the healing
  • The doctor treating you for high blood pressure may ask a nurse to take your blood pressure and report this to the

We also may disclose your medication information to other medical personnel outside the office practice that will provide medical treatment or services.

Example:

  • The treating doctor may send a sample of your blood to be tested at a lab and inform the lab of your condition and a brief medical history so the lab will know what tests to run.
  1. Payment: We may use and disclose your protected health information so that the treatment and services you receive may be billed to and payment collected from you, your insurance company or a third party.

Examples:

  • We may need to give your health plan copies of your physician’s chart notes about the treatment you received in the office for high blood pressure so your health plan will pay us or reimburse you for the treatment.
  • We may also tell your health plan about a blood pressure treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  1. Health Care Operations: We may use or disclose your protected health information for Office Practice operations. These uses and disclosures are needed to run the Office Practice and make sure that all our patients receive quality care.

Examples:

  • We may use your blood pressure measurements to review our treatment and services and evaluate the performance of our staff in caring for you.
  • We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective.
  • We may also combine medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services we offer.
  1. Business Associates: We may disclose your protected health information to Business Associates independent of the Office Practice and with whom we contract to provide services on our behalf. We will only make these disclosures after receiving satisfactory assurances that the Business Associate will properly safeguard your privacy and the confidentiality of your protected health information.

Examples:

  • We may contract with a company outside of the Office Practice to provide medical transcription services for the Office Practice or to provide collection services for past due accounts.
  1. Appointment Reminders: We may use and disclose your protected health information to contact you as a reminder that you have an appointment for treatment or medical This may be done through an automated system or by one of our staff members to your landline or wireless cell phone. If you are not at home, we may leave this information on your answering machine, voice mail or in a message left with the person answering the telephone.
  2. Health Related Benefits and Services: We may use and disclose your protected health information to tell you about health-related benefits or services to recommend possible treatment options or alternatives that may be of interest to you.
  3. Marketing: We may disclose certain protected health information to a third party to provide marketing materials and information to
  4. Facility Directory: We may release your name and general condition to people who ask for you by name so your family and friends can know generally how you are doing. If you do not want to be included in this directory, notify Office Practice personnel during registration.
  5. Individuals Involved in Your Care or Payment for Your Care: We may release protected health information to a friend or family member who is involved in your medical care. We may also give protected health information to someone who helps pay for your care. We may disclose protected health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  6. Research: Under certain circumstances, we may use and disclose your protected health information for research purposes or, to determine whether you might benefit from, or be willing to be involved in certain research.

Examples:

  • A research project may involve comparing the health and recovery of all patients with high blood pressure who received one blood pressure medication to those who received another type of blood pressure medication to determine which type is most effective.
  • We may disclose your protected health information to people preparing to conduct a research project so long as the protected health information they review does not leave the office.

Most research only uses medical information without using your name, address or other information that reveals who you are. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are or if your medical information will leave the office.

CAN YOU EVER USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION WITHOUT MY CONSENT?

Yes. The following categories describe ways we may use or disclose your protected health information without your consent. Not every use or disclosure in a category will be listed.

  1. Required by Law: We will disclose your protected health information when required to do so by federal, state or local

Example:

  • Oklahoma law requires us to report all communicable or venereal diseases which are identified or diagnosed in our office to the Oklahoma State Department of Health.
  1. To Avert a Serious Threat to Health or Safety: We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. This disclosure would only be made to someone able to help prevent the threat.
  2. Organ and Tissue Donations: If you are an organ donor, we may release your protected health information to organizations that handle organ procurement for organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
  1. Military: If you are a member of the Armed Forces, we may release your protected health information as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.
  2. Workers Compensation: We may release your protected health information for workers compensation or similar programs as authorized by State laws. The programs provide benefits for work related injuries or illness.
  3. Public Health Reporting: We may disclose your protected health information for public health Examples:
    • Prevention or control of disease, injury or disability reporting of birth defect or infant eye
    • Reporting of cancer diagnoses and
    • Reporting of reactions to medication or problems with
    • Notification of people using products that are
    • Notification of the Oklahoma State Department of Health about people who may have been exposed to a disease or at risk for contracting or spreading a disease or condition such as HIV, Syphilis or other sexually transmitted diseases.
    • Reporting of abuse, neglect or violence as required by law, including children who are born with alcohol or other substances in their
    • Reporting of births and
  4. Health Oversight Agencies: We may disclose protected health information to a health oversight agency for activities necessary for the government to monitor the health care system, government programs, and compliance with applicable laws. These oversight activities include, for example, audits, investigations, inspections, medical device reporting and licensure.
  5. Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose your protected health information in response to a court or administrative We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
  6. Law Enforcement: We may release protected health information if asked to do so by a law enforcement

Examples:

  • In response to a court order, subpoena, warrant summons or similar
  • To identify or locate a suspect, fugitive, material witness or missing
  • About a crime victim if, under certain circumstances, we cannot obtain your
  • About a death we believe may be the result of criminal
  • In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
  1. Coroners, Medical Examiners and Funeral Directors: We may disclose protected health information to a coroner, medical examiner or funeral director.

Examples:

  • To identify a deceased person or determine the cause of
  • To assist the funeral director in completing the death
  1. National Security and Intelligence Activities: We may disclose your protected health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
  2. Protective services for the President and Others: We may disclose your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
  3. Inmates: If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your protected health information to the correctional facility or law enforcement This may be necessary (1) for the correctional institution to provide you with health care or (2) to protect the health and safety of yourself, others or the correctional institution.

WHAT ARE MY RIGHTS REGARDING MY PROTECTED HEALTH INFORMATION?

You have the following rights regarding your protected health information that we maintain about you. You are required to submit a written request to exercise any of these rights for records we create and maintain.

  1. Right to Inspect and Copy: You have the right to inspect and request a copy of your protected health information, except as prohibited by If you request a copy of your protected health information, we may charge 25 cents per page. We may deny your request to inspect and copy in certain circumstances, such as a request for mental health records. If you are denied access to certain protected health information, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
  1. Right to Amend: If you feel that the protected health information created by us is incomplete or incorrect, you may request an amendment for as long as we maintain the information. You must provide a reason that supports your amendment request. If your request is not in writing or does not include a reason to support your request for amendment, we may deny your request for We may also deny your request if you ask us to amend information that:
    • We did not create, unless the person or entity that created the information is no longer available to make the
    • Is not part of the protected health information maintained by
    • Is not part of the information that you would be permitted to inspect or
    • Is accurate and
  2. Right to an Accounting of Disclosure: You have the right to request one free ‘accounting of disclosures’ every 12 months. This accounting does not include disclosures made for treatment, payment or healthcare Your request must state a time period which may not be longer than 6 years or include dates before April 14, 2003. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any charges are incurred.
  3. Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or healthcare You also have the right to request or limit the protected health information we disclose about you to a family member or friend.

Example:

  • You ask us not to use or disclose information about your

We are not required to agree with your request. If we do not agree, we will comply with your request unless the information is needed to provide you with emergency treatment or the use or disclosure is required by law.

Your request must include:

  • What information you want
  • The type of restriction you want, and
  • To whom you want the restriction to
  1. Right to Request Confidential Communications: You have the right to request that we communicate with you about your protected health information in a certain way or certain location.

Examples:

  • You request we only contact you via mail or at your work phone

We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

  1. Right to a Paper Copy of this Notice: You have the right to a paper copy of this You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy, contact our Privacy Officer.

CAN YOU CHANGE THIS NOTICE?

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for your protected health information we already have about you as well as for any protected health information we receive in the future. Each notice will have an effective date. Copies of the current notice will be posted. Additionally, at each visit for treatment or health care services, we will make available to you a copy of the current notice.

WHAT IF YOU WANT TO USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION FOR A PURPOSE NOT DESCRIBED IN THIS NOTICE?

Other uses and disclosures not covered by this notice or the laws that apply to us will only be made with your written authorization. In other words, the consent you already provided us will not be enough to use or disclose your protected health information for any purpose not described in this notice. If you provide us authorization to use or disclose your protected health information, you may revoke that authorization, we will no longer use or disclose your protected health information for the reasons covered by your authorization. You understand that we are unable to take back any uses or disclosures we have already made with your authorization.

WHAT IF I HAVE QUESTIONS OR NEED TO REPORT A PROBLEM?

If you believe your privacy rights have been violated, you may file a written complaint with us or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

To file a complaint with us, contact our Privacy Officer at: Tulsa Pain Consultants Consultants, 10810 East 45th Street, Ste 400, Tulsa, Oklahoma 74146. Phone 918-742-7030