Co-payments are due at the time of service for office visits including any follow up office visit(s). Co-pays are a
contract between you and your insurance company, therefore, MY DR NOW is unable to waive them. Based on
standard insurance and clinic guidelines, all payments, co-pays, and outstanding balances are due at the time
of service. MY DR NOW accepts all major insurance plans; additional forms of payments include Cash, Debit Cards, MasterCard, Visa, Discover and
American Express. As a service to you, MY DR NOW will process an insurance claim on your behalf. Not all insurance plans cover all services. In the
event your insurance plan determines a service is not a covered benefit, you will be responsible for the entire charge. Payment for past due patient
balances will be collected prior to obtaining additional services. To ensure all billing and financial matters are handled appropriately, MY DR NOW
engages a third party agency to review and process all refund requests and therefore cannot issue refunds in the facility under any circumstances.
For all self pay patients, payment is due in full at the time of service. This includes payment for any ancillary services including labs, x-rays,
immunizations, injections or procedures. At any time, if you choose to be seen as a self-pay patient, MY DR NOW will not be able to bill your insurance
carrier for the cost of the office visit. The self-pay fees are only available for self-pay patients who pay in full at the time of service.
If the injury is not approved, your insurance cannot be billed and the services will be your responsibility.
I have read and understand MY DR NOW’s patient policies, and I agree to be bound by its terms. I also understand and agree that such terms may be
amended by the practice from time to time. I understand that I am responsible for all charges regardless of insurance coverage.
I agree to pay my account with MY DR NOW in accordance with the standard rates and payment terms of this office. I understand that I have provided
all information including accurate and complete insurance information. If I do not provide all necessary information, it is my understanding I will be
responsible for all charges incurred for any and all visits at MY DR NOW.
I understand that a monthly late fee of $10 will be assessed for all patient balances over 30 days old. If it is deemed necessary, in the sole
discretion of this office, to take collection action as a result of nonpayment, I understand that any collection expenses incurred, including late fees,
attorney’s fees and contingency collection fees are my responsibility.
This notice describes how health information about you may be used and disclosed and how you can get access to
this information. Please review this notice carefully.
We understand that health information about you and your health care is personal. We create a record of the care and services you receive from MY DR NOW and are committed
to protecting health information about you. We are required by law to 1) Make sure health information that identifies you is kept private; 2) Give you this notice of our privacy
practices, and 3) Follow the terms of the notice that is currently in effect.
The following categories describe the different ways in which we may use and disclose your protected health information (PHI).
We may use and disclose your PHI without your written permission when we are required to do so by federal, state, or local law, such as for law enforcement purposes,
suspected abuse or neglect reporting, health oversights or audits, funeral arrangements, organ donation, public health purposes, or in an emergency.
We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us
regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons
described in the authorization. Please note, we are required to retain records of your care.
You have the following rights regarding the PHI that we maintain about you:
If you believe your privacy rights have been violated, you may file a complaint with our Officer Manager.
Minors and certain disabled adults are entitled to the privacy protection for their health information. Because by law, they cannot make health care decisions for themselves,
a parent or guardian can make medical decisions on their behalf. Therefore parents or guardians can authorize the use and release of PHI and also hold all rights listed in this
notice. Under certain situations defined by law, minors can make independent healthcare decisions without parent or guardian knowledge or consent. In those situations, the
minor may hold all rights listed in this notice. If the minor chooses to inform the parent or guardian, then all privacy rights regarding PHI may transfer to the parent or guardian.
There are also certain situations where access, use or release of a minor’s PHI may occur without the consent of the parent or guardian, i.e. when the health or safety of the minor
is in danger and PHI is necessary to protect the minor.
We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we have
created or maintained in the past, and for any we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible
location, and you may request a copy of our most current Notice at any time.
Please direct any questions about this notice to our Privacy Officer at (480) 677-8282