Privacy Policy
Each time you visit a hospital, physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination, test results, diagnosis, treatment and plan for future care or treatment. This information, often referred to as your medical record, serves as the following:
Understanding what is in your health record and how your Health Information is used helps you to:
In addition to providing you your rights as detailed below, the federal privacy standard required us to take the following measures:
Notice of Privacy Practices
We will not use or disclose your Health Information without your consent or authorization, except as described in this notice or otherwise required by law. Other uses and disclosure not described in this notice will be made only with your written authorization.
USES AND DISCLOSURE OF YOUR HEALTH INFORMATION:
The following are examples of the types of uses and disclosures of your Health Information that Summit PCP is legally permitted to make.
USES AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND OPERATIONS
Your Health Information may be used and disclosed by your physician and Summit PCP staff who are involved in your care and treatment. Your Health Information may also be used and disclosed as necessary for Summit PCP to obtain reimbursement for care provided to you and to support the operation of our practice.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES OF YOUR HEALTH INFORMATION:
In addition to treatment, payment and health care operations, there are other circumstances in which Summit PCP is either permitted or required to disclose your Health Information, in accordance with applicable law.
YOUR INDIVIDUAL RIGHTS
Although your medical record at Summit PCP is Summit PCP’s property, the Health Information it contains belongs to you. The following is a statement of your rights with respect to your Health Information and a brief description of how you may exercise these rights:
We are obligated by law to abide by such restriction. If we do, we must put the restriction in writing and abide by it except if you need to be treated in an emergency. You may not ask us to restrict uses and sharing of information that we are legally required to make. All requests must be in writing to Summit PCP’s Privacy Officer.
EFFECTIVE DATE: This Notice is effective on June 1, 2015
CHANGES OF THIS NOTICE
This Notice of Privacy Practice is subject to change, we may change our practices concerning how we use or disclose patient medical information or how we will implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices.
- Basis for planning your care and treatment.
- Means of communication among the many health professionals who contribute to your care.
- Legal documents describing the care that you received.
- Means by which you, or third-party payer, can verify that you actually received the service billed.
- Tool in medical education.
- Source of information for public health officials charged with improving the health of the regions that they serve.
- Tool to assess the appropriateness and quality of care that you received.
- Tool to improve the quality of health care and to achieve better patient outcome.
Understanding what is in your health record and how your Health Information is used helps you to:
- Ensure its accuracy and completeness.
- Understand who, what, where, why and how others may access your Health Information.
- Make informed decisions about authorizing disclosure to others.
- Better understand your Health Information rights detailed below.
In addition to providing you your rights as detailed below, the federal privacy standard required us to take the following measures:
- Maintain the privacy of your Health Information, including implementing reasonable and appropriate physical, administrative and technical safeguards to protect the information.
- Provide you this notice as to your legal duties and privacy practices with respect to individual identifiable Health Information that we collect and maintain about you.
- Abide by the term of this notice.
- Train our personnel concerning privacy and confidentiality.
Notice of Privacy Practices
We will not use or disclose your Health Information without your consent or authorization, except as described in this notice or otherwise required by law. Other uses and disclosure not described in this notice will be made only with your written authorization.
USES AND DISCLOSURE OF YOUR HEALTH INFORMATION:
The following are examples of the types of uses and disclosures of your Health Information that Summit PCP is legally permitted to make.
USES AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND OPERATIONS
Your Health Information may be used and disclosed by your physician and Summit PCP staff who are involved in your care and treatment. Your Health Information may also be used and disclosed as necessary for Summit PCP to obtain reimbursement for care provided to you and to support the operation of our practice.
- Treatment: Summit PCP may use your Health Information to provide and manage your health care. If we refer you for treatment or consultation outside Summit PCP⎯for example to another clinician or hospital⎯we will provide that health care provider with the necessary information to diagnose or treat you. We believe this type of sharing is critical in providing you the very best in health care and is necessary given the complexities of various illnesses and health conditions. We will also provide your physician, other health care professionals, or a subsequent health care provider copies of your records to assist them in treating you once we are no longer treating you.
- Payment: Summit PCP may use and disclose your Health Information, as needed, to obtain payment for health care services. We may disclose information to your health plan or other third party payer in order to make sure your treatment is approved, to verify eligibility or coverage for insurance benefits, and to permit the payer to review services provided to you for medical necessity. For example, we may send a bill to you or to a third-party payer, such as health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received and supplies used.
- Health Care Operations: Summit PCP may use or disclose your Health Information in order to conduct its business of providing health care. These "health care operations" may include quality assessment, training of medical staff, credentialing and various other activities that are necessary to run our practice and to improve the quality and cost effectiveness of the care that we deliver to you.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES OF YOUR HEALTH INFORMATION:
In addition to treatment, payment and health care operations, there are other circumstances in which Summit PCP is either permitted or required to disclose your Health Information, in accordance with applicable law.
- Involvement of Others in Your Health Care: Summit PCP will make an effort to ask you if we may share relevant Health Information about you with family members or any other person you identify. If you are not present, unable to communicate, or in an emergency situation, Summit PCP staff may exercise their professional judgment to determine whether to share this information. In addition, we may need to disclose Health Information to notify a family member, or any other person responsible for your care, of your location, general condition or death. Finally, Summit PCP may disclose your Health Information to an authorized public or private entity to assist in disaster relief efforts, and to coordinate efforts to notify someone on your behalf. Please be assured we will only do so if absolutely necessary and in the event of an emergency or disaster.
- Marketing/Continuity of Care: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If we contact you to provide marketing information for other products or services, you have the right to opt out of receiving such communications. If we receive compensation from another entity for marketing, we must obtain your signed authorization.
- Communication with Family: Unless you object, we, as healthcare professionals, using our best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify as relevant involvement to your overall health information, care management or payment options.
- Public Health: Summit PCP may disclose your Health Information for public health activities, including the following:
- To report Health Information (e.g., infectious diseases, such as chickenpox) to prevent or control disease, injury, or disability.
- To report births and deaths.
- To report reactions to medications or problems with products.
- To notify a person who may have been exposed to a communicable disease, or may be at risk for contracting or spreading the disease.
- Victims of Abuse, Neglect or Domestic Violence: If Summit PCP reasonably believes you are a victim of abuse, neglect or domestic violence, Summit PCP may disclose your Health Information to an appropriate agency authorized by law to receive such reports.
- Health Oversight: Summit PCP may be required to disclose Health Information to a health oversight agency for audits, investigations, inspections, and other health oversight activities. Oversight agencies include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
- Uses and Disclosures of Health Information Based upon Your Written Authorization: Uses and disclosures of your Health Information, other than those described above, will be made only with your written authorization. For example, you will need to sign an authorization form before Summit PCP can send your Health Information to your life insurance company. With limited exceptions, we will also obtain your written authorization prior to using your Health Information for marketing purposes. You may revoke your authorization at any time, in writing, except to the extent that Summit PCP has taken any action in reliance on the authorization.
YOUR INDIVIDUAL RIGHTS
Although your medical record at Summit PCP is Summit PCP’s property, the Health Information it contains belongs to you. The following is a statement of your rights with respect to your Health Information and a brief description of how you may exercise these rights:
- Right to Inspection: You have the right to inspect and obtain a copy of your Health Information. At any time, you may inspect and obtain a copy of Health Information about you, including your medical and billing record, which may be used to make decisions about your care. Under limited circumstances we may limit your access to all or certain portions of your record. This includes, but is not limited to, psychotherapy "process" notes, or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. If you are denied access to portions of your record, in some circumstances you may have a right to have this decision reviewed. All requests to access your record must be made in writing to the Health Information Management Department and will be processed in accordingly. If you request a copy of your records, we may charge you a fee to cover the copying and mailing costs, including related labor and supplies expenses, in compliance with the above cited regulations.
- Right to Correct: You have the right to request an amendment of your Health Information. You may request Summit PCP to amend your treatment and billing information if you think the information is incorrect or incomplete, for as long as Summit PCP maintains the information. If for some reason we deny your request, we must give you a written statement with the reasons for the denial and what other steps are available to you. We will respond to your request within the timeline permitted. If you have questions about amending your medical record, please don't hesitate to contact the Privacy Officer or any registration staff to discuss amendments to your billing records.
- Right to Restrict: You have the right to request a restriction of your Health Information. You have the right to ask for restrictions on the use and sharing of your Health Information for treatment, payment, or health care operations. Summit PCP is not required to agree to your request, except if you pay for a service entirely out-of-pocket. If you pay for a service entirely out-of-pocket, you may request that information regarding the service be withheld and not provided to a third party payor for purposes of payment or health care operations.
- Legal Proceedings: Summit PCP may be required to disclose Health Information in the course of any judicial or administrative proceeding in response to a legal order or other lawful process, including a subpoena.
- Law Enforcement: Summit PCP may be required to disclose Health Information for law enforcement purposes or in response to a valid subpoena
- Coroners, Funeral Directors, and Organ Donation: Summit PCP may be required to disclose Health Information to a coroner or medical examiner to identify a deceased person or to determine the cause of death. We may also disclose Health Information to a funeral director, or their designee, as necessary to carry out their duties. Health Information may also be disclosed to organizations that facilitate organ, eye or tissue donation and transplantation.
- Correctional Institution: If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof Health Information necessary for your health and the health and safety of other individuals.
- Research: Summit PCP may use or disclose Health Information for research that is approved by an Institutional Review Board when written permission is not required by Federal or State law. This may include preparing for research or telling you about research studies in which you might be interested.
- Food and Drug Administration (FDA): Summit PCP may disclose to the FDA Health Information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects or postmarking surveillance information to enable product recalls, repairs or replacement.
- Specialized Government Functions: Under certain circumstances, Summit PCP may be required to disclose Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State.
- Workers' Compensation: Summit PCP may use and disclose Health Information as required to comply with workers’ compensation laws, and other programs that provide benefits for work-related injuries or illnesses.
- Business Associates: We provide some services through contracts with business associates. When we use these services, we may disclose your Health Information to the business associates so that we can perform the function(s) that we have contracted with them to do and to bill you or third-party payer for services provided. To protect your Health Information, however, we require the business associates to appropriately safeguard your information. After February 17, 2010, business associates must comply with the same federal security rules as we do.
- Required By Law: Summit PCP may be required to use or disclose your Health Information to the extent that the use or disclosure is required by federal, state or local law. This includes any other law not already referred to in the preceding categories. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
We are obligated by law to abide by such restriction. If we do, we must put the restriction in writing and abide by it except if you need to be treated in an emergency. You may not ask us to restrict uses and sharing of information that we are legally required to make. All requests must be in writing to Summit PCP’s Privacy Officer.
- Right to Confidential Communication: You have the right to request to receive communications from us by alternative means or at an alternative location. We will make every effort to accommodate requests, provided you supply a valid alternative address or other method of contact. The Privacy Officer will handle all requests. In certain cases, we may need to contact you and may do so at the original address or phone number, if attempts to contact you at the alternative locations are not successful.
- Right to Accounting: You have the right to receive an accounting of certain disclosures we have made, if any, of your Health Information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It does not apply to disclosures we may have made to you, that were authorized by you, information provided to family members or friends about your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Requests must be made to our Privacy Officer, and we will respond to your request within 60 days.
- Right to Consent: You have the right to revoke your consent or authorization to use or discloses Health Information in writing, except to the extent that we have taken action in reliance on the consent or authorization.
- Right to Paper Notice: You have the right to obtain a paper copy of this notice. We will provide a paper copy of this Notice to you, upon request, even if you have agreed to accept this notice electronically.
- Right to Assign Authority: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
- Right to be Notified of a Breach: you have the right to be notified of a breach if we discover that a breach of your unsecured personal health information has occurred.
- Right to Complaint: You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
EFFECTIVE DATE: This Notice is effective on June 1, 2015
CHANGES OF THIS NOTICE
This Notice of Privacy Practice is subject to change, we may change our practices concerning how we use or disclose patient medical information or how we will implement patient rights concerning their information. We reserve the right to change this Notice and to make the provisions in our new notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices.
Financial policy
Summit Walk-In Clinic is recognized for providing complete on-demand healthcare. In order to provide care for you, we need an honest, clear, and direct financial relationship with you. We serve you directly, not your insurance company. As a result, you are ultimately responsible for paying for your care. The following policies explain how Summit Walk-In Clinic bills and collects payment for our services.
Acknowledgment of Financial Responsibility
You acknowledge that you are financially responsible for and agree to pay for all services/products received at Summit Walk-In Clinic. You acknowledge that payment is required at the time of service unless other arrangements, such as the billing of insurance, have been made. Payment for services includes payment of applicable coinsurance, copayments and deductibles for participating insurance companies. Summit Walk In Clinic accepts cash, VISA, MasterCard, Discover Card and American Express. Summit Walk In Clinic does not accept checks in the clinic.
Billing Insurance
As a courtesy to you, Summit Walk In Clinic will bill health insurers with which Summit Walk In Clinic has a contract. However, you understand and agree that you (not the insurance company nor any other entity) are ultimately responsible for all fees for services received at Summit Walk In Clinic. Or, unless otherwise specified by state or federal law or other billing arrangements have been made.
As a benefit to you, if you are using commercial health insurance, Summit Walk In Clinic will run an insurance benefit and eligibility check. This eligibility check will provide you and the clinic with your deductible information (if applicable), co-payment amount (if applicable), and some coverage information. It is your responsibility to understand your benefits and guidelines of your particular plan. We will always bill your insurance first. Many times however, there is a portion of the final bill that is not covered by insurance. Prior to your visit with us, if the amount remaining on your deductible is greater than $100.00, we offer 2 options for financial clarity.
Option 1: Credit Card on File.
During the check-in process, Summit Walk-In Clinic will collect your credit card information in our secure billing system. By keeping your credit card on file with Summit Walk In Clinic, any outstanding charges that have not been paid by your insurance company will be charged to the credit card on file. Your credit card is kept on file until the card expires to ensure that costs associated with any visit are covered. Acknowledging this policy implies consent for us to retain your card information and charge up to, but not more than, $500.00 per transaction for any fees related to your care.
Option 2: $100 Deposit prior to your Office Visit.
During the check-in process, you pay a $100 deposit in additional to any co-payments. After your visit is completed and we have billed your insurance first, any remaining balance that is due will be paid with the $100 that was deposited at check-in. If there is still a balance after the $100 deposit has been applied, Summit Walk-In Clinic will send you a bill. If any money remains from the $100 deposit, Summit Walk-In Clinic will automatically refund it to you.
No Shows and Late Policy for APPOINTMENT MADE VISITS ONLY
You authorize Summit Walk-In Clinic to keep your signature on file and to charge your credit card in the instance of a no-show, no-call or a late arrival of more than 30 minutes (please see our check-in policy for more information). A no-show, no-call charge is up to $100, and a late arrival fee is up to $50. This is a non-refundable Fee.
Assignment of Benefits Statement
If you have health insurance, you authorize your health insurance and health plans to make payments directly to Summit Walk-In Clinic on your behalf. You agree to pay for any charges that are not paid by your insurance.
You understand that if your primary health insurance or health plan does not pay Summit within 60 days of the date of service, Summit Walk-In Clinic may then bill you directly or charge your credit card on file the total amount due.
As a courtesy, Summit Walk-In Clinic will also bill secondary insurance policies. However, if payment is not received from any secondary insurer within 30 days of billing a secondary insurer, Summit Walk-In Clinic may then directly bill you or charge to your credit or debit card on file the total amount billed to the secondary insurer.
You are responsible for knowing your insurance benefits, guidelines, and any services that are covered by your insurance plan. You are responsible for paying Summit Walk-In Clinic for all services and products provided that are not covered by your insurance.
You understand that you are responsible for knowing whether you are eligible to use this insurance at the time of service at Summit Walk-In Clinic. It is your responsibility to provide Summit Walk-In Clinic with valid insurance information at every visit. If your insurance is not in effect at the time of service, Summit Walk In Clinic will charge you the full amount for services received.
Outstanding Balance and Collection Policy
You agree to pay any outstanding balance within 60 days of service.
Charges that are not paid after 90 days of service you will be transferred to a collection agency. If it becomes necessary to involve a collections agency for any amount owed on this or subsequent visits, you agree to pay all legal costs and expenses, including reasonable attorney fees. You hereby authorize Summit Walk-In Clinic to release information necessary to secure payment.
As of 8/24/2016
Acknowledgment of Financial Responsibility
You acknowledge that you are financially responsible for and agree to pay for all services/products received at Summit Walk-In Clinic. You acknowledge that payment is required at the time of service unless other arrangements, such as the billing of insurance, have been made. Payment for services includes payment of applicable coinsurance, copayments and deductibles for participating insurance companies. Summit Walk In Clinic accepts cash, VISA, MasterCard, Discover Card and American Express. Summit Walk In Clinic does not accept checks in the clinic.
Billing Insurance
As a courtesy to you, Summit Walk In Clinic will bill health insurers with which Summit Walk In Clinic has a contract. However, you understand and agree that you (not the insurance company nor any other entity) are ultimately responsible for all fees for services received at Summit Walk In Clinic. Or, unless otherwise specified by state or federal law or other billing arrangements have been made.
As a benefit to you, if you are using commercial health insurance, Summit Walk In Clinic will run an insurance benefit and eligibility check. This eligibility check will provide you and the clinic with your deductible information (if applicable), co-payment amount (if applicable), and some coverage information. It is your responsibility to understand your benefits and guidelines of your particular plan. We will always bill your insurance first. Many times however, there is a portion of the final bill that is not covered by insurance. Prior to your visit with us, if the amount remaining on your deductible is greater than $100.00, we offer 2 options for financial clarity.
Option 1: Credit Card on File.
During the check-in process, Summit Walk-In Clinic will collect your credit card information in our secure billing system. By keeping your credit card on file with Summit Walk In Clinic, any outstanding charges that have not been paid by your insurance company will be charged to the credit card on file. Your credit card is kept on file until the card expires to ensure that costs associated with any visit are covered. Acknowledging this policy implies consent for us to retain your card information and charge up to, but not more than, $500.00 per transaction for any fees related to your care.
Option 2: $100 Deposit prior to your Office Visit.
During the check-in process, you pay a $100 deposit in additional to any co-payments. After your visit is completed and we have billed your insurance first, any remaining balance that is due will be paid with the $100 that was deposited at check-in. If there is still a balance after the $100 deposit has been applied, Summit Walk-In Clinic will send you a bill. If any money remains from the $100 deposit, Summit Walk-In Clinic will automatically refund it to you.
No Shows and Late Policy for APPOINTMENT MADE VISITS ONLY
You authorize Summit Walk-In Clinic to keep your signature on file and to charge your credit card in the instance of a no-show, no-call or a late arrival of more than 30 minutes (please see our check-in policy for more information). A no-show, no-call charge is up to $100, and a late arrival fee is up to $50. This is a non-refundable Fee.
Assignment of Benefits Statement
If you have health insurance, you authorize your health insurance and health plans to make payments directly to Summit Walk-In Clinic on your behalf. You agree to pay for any charges that are not paid by your insurance.
You understand that if your primary health insurance or health plan does not pay Summit within 60 days of the date of service, Summit Walk-In Clinic may then bill you directly or charge your credit card on file the total amount due.
As a courtesy, Summit Walk-In Clinic will also bill secondary insurance policies. However, if payment is not received from any secondary insurer within 30 days of billing a secondary insurer, Summit Walk-In Clinic may then directly bill you or charge to your credit or debit card on file the total amount billed to the secondary insurer.
You are responsible for knowing your insurance benefits, guidelines, and any services that are covered by your insurance plan. You are responsible for paying Summit Walk-In Clinic for all services and products provided that are not covered by your insurance.
You understand that you are responsible for knowing whether you are eligible to use this insurance at the time of service at Summit Walk-In Clinic. It is your responsibility to provide Summit Walk-In Clinic with valid insurance information at every visit. If your insurance is not in effect at the time of service, Summit Walk In Clinic will charge you the full amount for services received.
Outstanding Balance and Collection Policy
You agree to pay any outstanding balance within 60 days of service.
Charges that are not paid after 90 days of service you will be transferred to a collection agency. If it becomes necessary to involve a collections agency for any amount owed on this or subsequent visits, you agree to pay all legal costs and expenses, including reasonable attorney fees. You hereby authorize Summit Walk-In Clinic to release information necessary to secure payment.
As of 8/24/2016
narcotics policy
We understand that some patients have chronic pain needs and medications. However,
it is our policy at Summit Primary Care & Walk-In Clinic, that we do NOT refill any narcotic prescriptions, including benzodiazepines and stimulants.
We will be happy to refer you to one of the local specialists that can assist you with your needs.
it is our policy at Summit Primary Care & Walk-In Clinic, that we do NOT refill any narcotic prescriptions, including benzodiazepines and stimulants.
We will be happy to refer you to one of the local specialists that can assist you with your needs.
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Narcotic Example:
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Benzodiazepine Examples:
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Stimulant Examples:
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Durable medical equipment (dme) Sales
ALL DME SALES ARE FINAL
Durable Medical Equipment (DME) includes:
The Summit Team
Durable Medical Equipment (DME) includes:
- Crutches
- Walking Boots
- Slings
- Splints/Casts
The Summit Team
