Practice policies

Patient Financial Responsibility

PATIENT FINANCIAL RESPONSIBILITY FORM

Thank you for choosing Ally Endocrinology, as your healthcare provider. We are committed to providing you with quality healthcare. Please completely read and sign this form to acknowledge your understanding of our patient financial policy.

INSURANCE COVERAGE:

• It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions, authorization and limitation requirements. This information can be found by calling your insurance company or visiting their website.
• If insurance is not valid at the time of your visit, all financial responsibility will then become the patients or the responsible party.
• It is your responsibility to give us updated information and new insurance information as soon as you receive it.
• Medicare and some insurance companies will not preauthorize procedures. We cannot guarantee payment. Medicare and other insurance companies consider benign lesions not medically necessary; the patient is responsible for these costs not covered by Medicare.

CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES:

• All co-payments, co-insurance and deductibles are the patient’s responsibility. Co-payments are due at the time of each visit.
• Deductibles are patient’s responsibility. You may be asked for a portion of your deductible upfront prior to your procedure.

REFERRALS:

• It is the responsibility of the patient to obtain a referral if required by their insurance company.
• Not obtaining a referral will result in a denial of the claim and the responsibility of payment being transferred to the patient or the responsible party.
• It is the patient’s responsibility to verify network participation of your physician with your insurance company. As a courtesy we will bill your insurance carrier. However, if we are not a participating/contracted provider with your carrier, you will be billed for services rendered.

NON-COVERED SERVICE:

• You are responsible for any and all “non-covered” and “not medically necessary” services if denied by your insurance carrier.
• We cannot guarantee that Medicare or other insurance companies will cover a procedure, if the insurance company deems the procedure “not medically necessary”, it then becomes the patient’s responsibility.
• Medicare and other insurance companies will not preauthorize procedures. We cannot guarantee payment. Medicare and other insurance carriers consider benign lesions not medically necessary; the patient is responsible for these costs not covered by Medicare.
• Prior authorizations are not a guarantee of payment, if claim is denied, patient will then be responsible.

INSURANCE REQUEST:

• You are responsible for promptly responding to any request from your insurance company for further information. Not doing so will result in a claim denial and you will then be responsible for payment.

INSURANCE PAYMENTS SENT TO YOU:

• If insurance payments are sent to you, it is your responsibility to forward them to our office with any documentation or explanation of benefits pertaining to the claim.

COLLECTION ACCOUNTS:

• If your account is sent to our collection agency, it is your responsibility to pay all attorney fees, if applicable.

PAYMENT DUE AT TIME OF SERVICE:

• We accept cash, checks, debit and credit cards.
• Patient balances are due at the time of check-in unless payment agreements have been arranged with our office manager.

Patient Conduct Policy

Professional Conduct:

1. Maintain professionalism and respect in all online interactions related to the medical practice, its staff, and other patients.
2. Avoid engaging in any form of discriminatory, offensive, or inappropriate content, including but not limited to racism, sexism, or privacy breaches of others.

Personal Responsibility:

1. Recognize that the medical practice’s social media accounts are intended for informational purposes and not a platform for seeking personal medical advice.
2. Exercise caution when discussing personal medical information online, as it may compromise your privacy or that of others.
3. Be mindful of the potential consequences of sharing misleading or false medical information, as it can negatively impact others’ health decisions.

Confidentiality and Privacy:

1. Understand that sharing personal medical information, including photos, in public forums or social media platforms can breach your own privacy and that of others.
2. Respect the confidentiality and privacy of other patients by refraining from sharing identifiable information or discussing medical conditions without explicit consent.

Respect for Others:

1. Engage in respectful and considerate communication when interacting with the medical practice’s staff and other patients online.
2. Avoid engaging in disputes, trolling, or harassing behavior that may harm others’ well-being or the reputation of the medical practice.
3. Do not share defamatory or misleading information about the medical practice or its staff, as it can undermine trust and harm professional relationships.

Compliance with Policies:

1. Acknowledge and abide by the terms of use, community guidelines, and privacy policies of the medical practice’s social media platforms when engaging with their content.
2. Direct any concerns or issues regarding the medical practice’s social media policies to the Practice Manager, who can be contacted through the designated communication channels.

Consequences of Violations:

1. Practice patients are expected to present their concerns to the practice management for resolution. Posting a negative review on social media such as Google, Facebook should be considered as a last option; and done only after the concerns are not resolved. Posting of any form of negative review on any social media website such as (and not limited to) Google, Facebook etc. is a violation of our social media policy and could result in a removal from the practice.
2. The medical practice reserves the right to take appropriate action, including legal measures, to protect the rights, safety, and well-being of its staff, patients, and the integrity of its online communities.

Telehealth Informed Consent

Telehealth Informed Consent

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

• I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.

• I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Michigan at the time of this service.

• I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

• I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.

By signing this consent, I certify that I have read and understand this agreement.

Notice of Privacy Practices

Notice of Privacy Practices

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

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is legally required to maintain the confidentiality of your PHI, and to follow specific rules when using or disclosing this information. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules when using or disclosing your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under The Privacy Rule

Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff. You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices We are required by law to follow the terms of this Notice. We reserve the right to change the terms of the Notice, and to make the new Notice provisions effective for all PHI that we maintain. We will provide you with a copy of our current Notice if you call our office and request that a revised copy be sent to you in the mail, or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location in the practice, and if such is maintained, on the practice’s website.

You have the right to authorize other use and disclosure – This means we will only use or disclose your PHI as described in this Notice unless you authorize other use or disclosure in writing. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/ phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and obtain a copy your PHI* – This means you may submit a written request to inspect or obtain a copy of your complete health record, or to direct us to disclose your PHI to a third party. If your health record is maintained electronically, you will also have the right to request a copy in electronic for- mat. We have the right to charge a reasonable, cost-based fee for paper or electronic copies as established by federal guidelines. We are required to provide you with access to your records within 30 days of your written request unless an extension is necessary. In such cases, we will notify you of the reason for the delay, and the expected date when the request will be fulfilled.

You have the right to request a restriction of your PHI* – This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You have the right to request an amendment to your protected health information* – This means you may submit a written request to amend your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability* – You may submit a written request for a listing of dis- closures we have made of your PHI to entities or persons outside of our practice except for those made upon your request, or for purposes of treatment, payment or healthcare operations. We will not charge a fee for the first accounting provided in a 12-month period.

You have the right to receive a privacy breach notice – You have the right to receive written notification if the practice discovers a breach of your unsecured PHI and determines through a risk assessment that notification is required.

How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment – We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Payment – Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health- care services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations – We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Special Notices – We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests, to provide information that describes or recommends treatment alternatives regarding your care, or to provide information about health-related benefits and services offered by our office. We may contact you regarding fundraising activities, but you will have the right to opt out of receiving further fundraising communications. Each fundraising notice will include instructions for opting out.

Health Information Organization – The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare – Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation), then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures – We are also permitted to use or disclose your PHI without your written authorization, or providing you an opportunity to object, for the following purposes: if required by state or federal law; for public health activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or domestic violence; to avert a serious threat to health or safety; for research purposes; in response to a court or administrative order, and subpoenas that meet certain requirements; to a coroner, medical examiner or funeral director; to respond to organ and tissue donation requests; to address worker’s compensation, law enforcement and certain other government requests, and for specialized government functions (e.g., military, national security, etc); with respect to a group health plan, to disclose in- formation to the health plan sponsor for plan administration; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints

You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.

You may ask questions about your privacy rights, file a complaint, or submit a written request (for access, restriction, or amendment of your PHI or to obtain a disclosure accountability) by notifying our Privacy Manager at:

If you have questions regarding your privacy rights or would like to submit any type of written request described above, please feel free to contact our Privacy Manager.