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NOTICE OF PRIVACY PRACTICES – HIPAA STATEMENT
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FINANCIAL RESPONSIBILITY POLICY
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Please contact our office to schedule an appointment. We will make every effort to schedule an appointment at a time most convenient for you. Because some visits require more time than others, please provide the receptionist with as many details as possible when making your appointment. If you are a new patient to our office, or if you have not been seen for over a year, you may print out, complete, and bring with you to your appointment, the Patient History form, Patient Information form, Insurance Authorization / Financial Responsibility / Privacy Notice Acknowledgment form, Authorization for Release of Medical Records form, Authorization for Consultation / Release of Financial Information form, and, if needed, Authorization for Release of Medical Records to North Shore Orthopaedics, S.C. To select a form, go the Forms section below and click on the name of the form you would like to print. Completion of these forms prior to your appointment will save you time in registering.
Although every effort is made to see you at your scheduled appointment time, emergencies can occur and delays may be inevitable. A sincere effort is made to adhere to the appointment schedule as closely as possible. Please contact our office 24 hours in advance if you need to cancel or reschedule an appointment. Please call 414 351-3500 to cancel or reschedule an appointment.
If you must cancel an appointment, please contact us as soon as possible so that we may fill our physician's schedule. Cancellations with notice provided less than 24 hours in advance of an appointment will be considered a "late cancellation." No cancellation notice in advance of your appointment will be considered a "no-show." Three such missed appointments in any 12-month period may result in your classification by your physician as a chronic no-show and/or non-compliant patient. Your physician reserves the right to terminate the physician-patient relationship pursuant to non-compliance.
North Shore Orthopaedics, S.C. requires payment at the time of service for co-pays as required by your health insurance. This is a condition of your contract with your insurance carrier. Required co-pays can not be waived or billed to you at a future date. We may be required under our contract with your insurance to reschedule your appointment if you do not have your co-pay. For your convenience, payment may be made by cash, check, VISA or MasterCard.
Authorizations for treatment, or referrals, if your specific health insurance policy requires them, must be in our office in order for us to provide care to you. You must verify that your required Primary Care Physician and/or insurance company’s referral is in our office prior to your appointment. If we do not have authorization from your insurance company to provide treatment to you, you will need to reschedule your appointment allowing sufficient time for your referral to be received.
We will make every attempt to provide and refill prescriptions in a timely manner during normal business hours, Monday through Friday. Because the physician that is on-call is not familiar with the care being provided to each patient in the practice, we will not refill prescriptions after 4:30 p.m. weekdays, during the weekend, or on holidays. Prescriptions may be refilled by calling our office and speaking with your physician’s medical assistant. The medical assistant will contact you or your pharmacy after the refill has been authorized by your physician.
If you should have a medical emergency, please go to the emergency room of the hospital nearest you.
Fees are for services provided and include: Evaluation, decision-making, and reading of x-rays by the physician; preparation of medical records and x-rays; and other services that may be provided by our staff.
Medical Records / X-Rays:
In order to provide continuity of care and accurate record keeping, Wisconsin state law allows medical records, including radiological files, to become the property of the institution taking them and/or the physician ordering them, and they must legally be retained for a minimum period of five years. We are happy to arrange copies and mailings in the event you need the records sent elsewhere. Should you require your medical records, you must either (1) provide our office with a written request, stating to whom this information should be released; or (2) sign one of our authorizations. Signing one of our authorizations will allow you to request your medical records by telephone, thus avoiding having to make a written request. Please allow five working days for chart retrieval and copy service.
At the time of service, patients seeking treatment for a work-related injury should be prepared to provide their employer’s complete business name, the physical address where they work, a supervisor or human resource contact name with telephone number, and the name and address of their your employer’s worker’s compensation carrier. Personal health information must also be provided in the event the worker’s compensation claim is denied.
Insurance and Payments:
We will file insurance claims for you. If you are a new patient, you must present your insurance
card(s) at your visit. It is your responsibility to pursue disagreements over benefits with your insurance carrier(s), although we will be happy to assist you where we are able. Ultimately, however, the patient is responsible for payment of our charges, not the insurance company. Any balance remaining after your insurance indicates that it has met its responsibility will be billed to you. You will receive a monthly statement from our office informing you of the status of your account. If you have questions regarding a balance, insurance processing, or difficult financial circumstances, we strongly encourage you to contact our business department. We will be happy to answer your call and look for a mutually acceptable payment plan.