A Full Service Medical Center for Your Health Care Maintenance & Acute Care Needs

Privacy & Policies

HIPPA Privacy Practices and Policies

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

The Health Insurance and Portability & Accountability Act of 1996 (HIPPA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information.

As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

♦  Treatment means providing, coordination, or managing health care and related services by one or more health care providers.

  • Example: A physical examination.

♦  Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.

  • Example: Sending a bill for your visit to your insurance company for payment.

♦  Health Care Operations include the business aspects of running your practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service.

  • Example: An internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and service that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

♦  The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other personal identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

♦  The right to reasonable request to receive confidential communication of protected health information from us by alternative means or at alternative locations.

♦  The right to inspect and copy your protected health information.

♦  The right to amend your protected health information.

♦  The right to receive an accounting of disclosures of protected health information.

♦  The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of your legal duties and privacy practices with respect to protected health information.

This notice is effective as of January 1, 2012, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of your Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPPA or to file a complaint, you may contact:

            The U.S. Department of Health & Human Services
            Office of Civil Rights
            200 Independence Avenue S.W.
            Washington, DC 20201
            (202) 619.0257 or Toll Free (877) 696.6775

Payment Policy

Thank you for choosing Mountain Medical Center (MMC) as your primary care provider. We are committed to providing you with high quality, affordable health care, and we strive to keep our prices representative of the usual and customary charges for our area. Please read the payment policy below regarding patient and/or insurance responsibility for services rendered, ask any questions you may have, and sign in the space provided. 
A copy of this policy will be provided to you upon request.

--  Insurance. If you are not insured by a plan we do business with, payment in full is expected at each visit. 
If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

--  Proof of Insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

--  Co-Payments. All co-payments must be paid at the time of service. We cannot bill them to you later.
This arrangement is part of your agreed upon contract with your insurance company. Failure on our part to collect co-payments from patients, while billing insurance, can be considered fraud. Please help us in upholding the law by paying your co-payment at the time of each visit.

--  Claims Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

--  Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

--  Non-Covered Services. Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by your insurance company. You must pay for these services in full at the time of your visit (or as soon as your insurance company denies coverage of the services).

--  Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 15 days to pay your balance in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this it to occur, you will be notified by standard mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis. If you have unusual financial hardship or other extenuating circumstances, please let us know that.

--  Missed Appointments. We charge $20 for appointments not canceled at least 24 hours prior to the scheduled appointment time. If you “No Show” for your appointment without calling us, there will also be a $20 fee charged. These charges will be your responsibility and will be billed directly to you. Please help us to serve you better by keeping your appointments.

I understand I am financially responsible for all charges, whether covered or not covered by Insurance. I understand MMC may bill my insurance company for me if it is one with which they normally contract. If not, I understand that payment is due at the time of service. If I need to make special arrangements in regards to payment, I understand that I need to discuss this with the office staff. I understand a 30% collection fee will be added to my charges if sent to collection. Additionally, a returned check fee of $25 will be applied if a check is returned to us by the bank due to insufficient funds.

I request that payment of authorized insurance benefits, including Medicare benefits, be made either to me or on my behalf to MMC for any services furnished to me by the physician/provider/nursing staff. I authorize any holder of medical information about me to release any information necessary to process/pay the claim. If “Other Health Insurance” is indicated in item 9 of the HCFA 1500 Form, or elsewhere on the other approved claim forms of electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician/provider/supplier agrees to accept the charge determination of the Medicare Carrier as the full charge, and the patient is only responsible for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare Carrier. I permit a copy of this authorization to be used in place of the original. This authorization is in force indefinitely, until it is either cancelled or changed in writing by me.

Medication Refill Policy

When requesting a refill of a medication, please allow 48-72 hours for processing. 

--  Call the Pharmacy where your prescription was last filled to insure that you do not already have refills available.

--  If refills are not available, please request the Pharmacy to fax a refill request to our office. This fax will contain important information needed to complete the request in a timely manner.

  • If your medication is a controlled substance and must be hand carried to the pharmacy, the pharmacist will request you call us directly.

  • Please remember it may take 48-72 hours to complete the request.

--  Many Insurance companies are mandating patients use mail order pharmacies.

  • If your insurance requires you to use a certain pharmacy, please contact that company to find out what forms they require from you.

  • Please get their Fax # and Electronic Prescribe ID#.

  • We will issue prescriptions to you and you must mail them to the specified pharmacy.

  • If you have contacted the mail order pharmacy and you have the required forms completed, we can fax the prescriptions from our office.

--  Please remember that we need 48-72 (business) hours to process refill requests. Do not wait until you are completely out of medication or you will likely do without until the refill can be processed.

--  Keep in mind that mail order takes longer to process – please request refills from them three (3) weeks in advance.


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