CONSENT FOR MEDICAL CARE I give consent to Dr. Hetal Shah, its staff, physicians and other practitioners (collectively, the “Practice”) to provide and perform such medical care, tests and other services that are deemed necessary or beneficial by the Practice for my health and well-being. I understand that the Practice is entirely virtual (“telemedicine” or “telehealth”) and that I will not be evaluated in person. Therefore certain limitations exist regarding diagnostic capabilities within the Practice (for example but not limited to assessment of vital signs or performance of a physical exam). I understand that the Practice is considered adjunct, consultative care and is not considered to be a provider of my primary, acute or urgent care at any time. I acknowledge the need to obtain and maintain a relationship with a primary care provider of my choice to provide advice and treat any acute, chronic or urgent medical needs that are unable to be addressed in a consultative telemedicine/virtual practice environment by the Practice. I understand that my primary care professional may not agree with the necessity for – or the Practice’s interpretation of – any particular care, test or other service provided by the Practice. If I have any concerns regarding this, I agree to discuss them with the Practice and with my primary care professional. I understand that the Practice is not available to address urgent or acute care needs. The Practice does not maintain an answering service or any “on-call” services to address any medical needs. I agree to have any urgent, acute or emergency care needs addressed by contacting my primary care provider’s office, calling 911 emergency services or by proceeding to an urgent care facility or the emergency department of a hospital, whichever is appropriate. FEES AND PAYMENT POLICIES Fees:Fees for products and services provided by Dr. Hetal Shah are charged by hour. The fee schedules have been established after careful consideration of what is just and fair based on the specialized services provided. This takes into account the experience and expertise of our staff and the customary fee in our geographic area. Cancellation Policy: Your appointment time is reserved for you. The hourly fee for any missed appointments is charged and will not be refunded unless you provide the office with at least 24 hours prior notice Payment: Payment is required at the time of scheduling a service via credit card or HSA card. You will be required to provide a credit card number to be kept on file for forgotten payments, missed appointments, and out of office appointments. Returned checks and late payments may be subject to an additional late payment fee. Failure to pay your bill in a timely manner or ongoing noncompliance with payment terms may incur collections charges and your bill may be sent to a collection agency. Missed Payments:All products and services need to be paid in full at the time the product or service is either scheduled or provided to you. Should you miss more than one appointment, or any payment due to decline of your credit card on file or failure to provide payment, your provider’s practice will discuss with you plans to resolve your balance prior to, but not later than the beginning of your next appointment. Late fees may be assessed. All outstanding balances must be resolved by the end of each calendar month, in order to avoid certain late charges. INSURANCE We do not accept insurance. Dr. Hetal Shah providers do not participate in any managed care networks or any type of insurance. You may request an insurance reimbursement invoice to submit to your insurance. Dr. Hetal Shah’s providers are considered “Out of Network Providers,” as they are not participating providers of any insurance plans. Medicare/Medicaid: Dr. Hetal Shah, LLC providers are not able to see patients covered by Medicare, Medicaid or other government medical payment programs. By choosing to work with Dr. Hetal Shah, LLC, the patient and/or their legal representative acknowledge that the patient is not covered by Medicare, Medicaid, TRICARE or other government sponsored benefit. Government payments will not be made for any products or services through Dr. Hetal Shah, including that of any particular service provided that may have been otherwise eligible for submission to any government payor were it not for the presence of this private contract. Medigap plans and other supplemental plans may elect not to reimburse for products or services provided by Dr. Hetal Shah, which are not covered by Medicare. The patient acknowledges that he/she freely enters this contract with the knowledge of the patient’s right to obtain Medicare covered services from providers who have not opted out of Medicare, and understands that the patient is not compelled to enter into private contracts with providers who have opted out of Medicare.
Dr. HETAL SHAH HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Dr. Hetal Shah (“Dr. Hetal Shah”) is required by law to maintain the privacy of your health information, to provide to you (or your representative) this Notice of Privacy Practices (“Notice”) of our duties and privacy practices, and to notify you (or your representative) following a breach of your unsecured health information. Dr. Hetal Shah is required to abide by the terms of this Notice as may be amended from time to time. Dr. Hetal Shah has the right to change the terms of this Notice. Any revisions to this Notice will be effective for all health information that Dr. Hetal Shah has created or maintained in the past, and for any records that Dr. Hetal Shah creates or maintains in the future. Dr. Hetal Shah will post our current Notice in a prominent location in our facility, as well as on our website. USE AND DISCLOSURE OF HEALTH INFORMATION THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND THE PURPOSES FOR WHICH Dr. Hetal Shah MAY USE OR DISCLOSE YOUR HEALTH INFORMATION: To Provide Treatment. Dr. Hetal Shah may use your health information to treat you and coordinate your care within Dr. Hetal Shah. For example, your attending physician or other health care professionals involved in your care may use information about your symptoms in order to prescribe appropriate medications. Dr. Hetal Shah may also disclose your health information to individuals outside Dr. Hetal Shah involved in your care, including family members, suppliers of medical equipment or other health care professionals. To Obtain Payment. Dr. Hetal Shah may use or disclose your health information to bill or collect payment for services or items you receive from Dr. Hetal Shah. For example, Dr. Hetal Shah may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Dr. Hetal Shah. Dr. Hetal Shah may also need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you. To Conduct Health Care Operations. Dr. Hetal Shah may use your health information for our own operations in order to facilitate the function of Dr. Hetal Shah and as necessary to provide quality care to all Dr. Hetal Shah patients. For example, Dr. Hetal Shah may use your health information to evaluate our staff performance, combine your health information with that of other Dr. Hetal Shah patients to evaluate how to more effectively serve all Dr. Hetal Shah patients, disclose your health information to Dr. Hetal Shah staff and contracted personnel for training purposes, or use your health information to contact you or your family as part of general community information mailings. Dr. Hetal Shah may also disclose your health information to a health oversight agency performing activities authorized by law, such as investigations or audits. These agencies include governmental agencies that oversee the health care system, government benefit programs and organizations subject to government regulation and civil rights laws. In addition, Dr. Hetal Shah may disclose your health information to another health care provider subject to Federal privacy protection laws, as long as the provider has or has had a relationship with you and the information is for that provider’s health care operations. To Inform You About Health Information That May Be of Interest to You. Dr. Hetal Shah may use or disclose your health information to tell you about or recommend possible options or alternatives for your care, or to inform you of other information that may be of interest to you. Release of Information to Family or Friends. Unless you specifically request in writing that Dr. Hetal Shah not communicate with such person(s), Dr. Hetal Shah may release your health information to a family member or friend who is involved in your treatment or who is helping pay for your care. Business Associates. Dr. Hetal Shah may disclose your health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for them to provide such functions or services. Dr. Hetal Shah requires our business associates to agree in writing to protect the privacy of your health information, and to use and disclose your health information only as specified in that written agreement. THE FOLLOWING IS A SUMMARY OF THE OTHER CIRCUMSTANCES UNDER WHICH AND THE OTHER PURPOSES FOR WHICH Dr. Hetal Shah MAY USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN CONSENT OR AUTHORIZATION: When Legally Required. Dr. Hetal Shah will disclose your health information to the extent that it is required to do so by any Federal, State or local law. When There Are Risks to Public Health. Dr. Hetal Shah may disclose your health information for the following public activities and purpose – To prevent or control disease, injury or disability, report disease, injury, vital events such as death, and the conduct of public health surveillance, investigations and interventions. – To report adverse events, product defects, to track products or enable product recalls, repairs and replacements, and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration. – To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease. – To an employer about an individual who is a member of the workforce, as legally required. To Report Abuse, Neglect or Domestic Violence. Dr. Hetal Shah is allowed to notify government authorities if Dr. Hetal Shah reasonably believes a resident is the victim of abuse, neglect or domestic violence. Dr. Hetal Shah will make this disclosure only when specifically required or authorized by law or when you authorize the disclosure. To Conduct Health Oversight Activities. As permitted or required by State law, Dr. Hetal Shah may disclose your health information to a health oversight agency for activities such as audits, civil, administrative or criminal investigations, inspections, and licensure or disciplinary action. If, however, you are the subject of a health oversight agency investigation, Dr. Hetal Shah may disclose your health information only if it is directly related to your receipt of health care or public benefits. In Connection With Judicial and Administrative Proceedings. As permitted or required by State law, Dr. Hetal Shah may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. Under certain conditions, Dr. Hetal Shah also may disclose your health information in response to a subpoena, discovery request or other lawful process. For Law Enforcement Purposes. As permitted or required by State law, Dr. Hetal Shah may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. To Coroners and Medical Examiners. Dr. Hetal Shah may disclose your health information to coroners and medical examiners for purposes of determining cause of death or for other duties, as authorized by law. To Funeral Directors. If necessary to carry out their duties, Dr. Hetal Shah may disclose your health information to funeral directors prior to and in reasonable anticipation of, or following, your death, consistent with applicable law. For Organ, Eye or Tissue Donation. Dr. Hetal Shah may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation For Research Purposes. Dr. Hetal Shah may, under very select circumstances, use or disclose your health information for research. Before Dr. Hetal Shah discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. In the Event of a Serious Threat to Health or Safety. Dr. Hetal Shah may, consistent with applicable law and ethical standards of conduct, disclose your health information if Dr. Hetal Shah, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or to the health and safety of the public. For Specified Government Functions. In certain circumstances, the Federal regulations authorize Dr. Hetal Shah to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.= For Worker’s Compensation. Dr. Hetal Shah may release your health information for worker’s compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than as stated above, Dr. Hetal Shah will not use or disclose your health information other than with your written authorization. Your authorization (or the authorization of your representative) is specifically required before Dr. Hetal Shah: (1) uses or discloses your psychotherapy notes; (2) uses your health information to make a marketing communication to you for which it receives financial remuneration from a third party, unless such communication is face-to-face or in other limited circumstances; or (3) discloses your health information in any manner that constitutes the sale of such information under HIPAA. Also, some types of health information are particularly sensitive, and the law, with limited exceptions, may require that Dr. Hetal Shah obtain your authorization to use or disclose that information. Sensitive information may include information dealing with genetics, HIV/AIDS, mental health, developmental disabilities, and alcohol and substance abuse. If required by law, Dr. Hetal Shah will ask that you (or your representative) sign an authorization before we use or disclose such information. If you (or your representative) authorize Dr. Hetal Shah to use or disclose your health information, you (or your representative) may revoke that authorization in writing at any time, except to the extent that it has already been acted upon. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION YOU HAVE THE FOLLOWING RIGHTS REGARDING YOUR HEALTH INFORMATION THAT Dr. Hetal Shah MAINTAINS: Receive Confidential Communications. You (or your representative) have the right to request that Dr. Hetal Shah communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that Dr. Hetal Shah only communicate with you about your health privately with no other family members present. All requests for confidential communications must be made in writing using the appropriate Dr. Hetal Shah form. This form can be requested by contacting the Privacy Officer at855.998.4900. Such requests shall specify the requested method of contact or the location where you wish to be contacted. Dr. Hetal Shah will accommodate reasonable requests. You (or your representative) do not need to give a reason for your request. Right to Request Restrictions. You (or your representative) have the right to request restrictions on certain uses and disclosures of your health information. For example, you (or your representative) may request a limit on Dr. Hetal Shah’s disclosure of your health information to someone who is involved in your care or the payment of your care. All requests for restrictions must be made in writing using the appropriate Dr. Hetal Shah form. This form can be requested by contacting the Privacy Officer at855.998.4900. Dr. Hetal Shah is not required to agree to your request; however, if we do agree, we are bound by that agreement except when otherwise required by law or in emergencies. Except as otherwise required by law, Dr. Hetal Shah must agree to a restriction if: (1) the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and (2) the health information pertains solely to a health care item or service for which Dr. Hetal Shah has been paid out of pocket, in full, by you or someone else on your behalf (not the health plan). If you self‑pay and request a restriction, it will apply only to those health records created on the date that you received the item or service for which you, or another person (other than the health plan) on your behalf, paid in full, and which document the item or service provided on such date. Right to Inspect and Copy Your Health Information. You (or your representative) have the right to inspect and copy your health information, including billing records. All requests to inspect and copy records must be made in writing using the appropriate Dr. Hetal Shah form. This form can be requested by contacting the Privacy Officer at855.998.4900. If you (or your representative) request a copy of your health information, Dr. Hetal Shah will provide you (or your representative) a copy of your records in the format you request, unless we cannot practicably do so. Dr. Hetal Shah may charge a reasonable fee for any copying and assembling costs associated with your request. Dr. Hetal Shah may deny your request to inspect and/or copy your health information in certain limited circumstances. If Dr. Hetal Shah denies your request, you (or your representative) may request that we provide you with a review of our denial. Reviews will be conducted by a licensed health care professional who we have designated as a reviewing official, and who did not participate in the original decision to deny the request. Right to Amend Your Health Information. If you (or your representative) believe your health information is incorrect or incomplete, you (or your representative) have the right to request that Dr. Hetal Shah amend your records. That request may be made as long as Dr. Hetal Shah still maintains your records, and must include a reason for the amendment. All requests for amendment must be made in writing using the appropriate Dr. Hetal Shah form. This form can be requested by contacting the Privacy Officer at855.998.4900. Dr. Hetal Shah may deny the request if it is not in writing or does not include a reason for the amendment. The request may also be denied if the requested amendment pertains to your health information that was not created by Dr. Hetal Shah, if the records you are requesting to amend are not part of Dr. Hetal Shah’s records, if the health information you wish to amend is not part of the health information you (or your representative) are permitted to inspect and copy, or if, in the opinion of Dr. Hetal Shah, the records containing your health information are accurate and complete. Right to an Accounting. You (or your representative) have the right to request an accounting of disclosures of your health information made by Dr. Hetal Shah for certain purposes. All requests for an accounting must be made in writing using the appropriate Dr. Hetal Shah form. This form can be requested by contacting the Privacy Officer at 855.998.4900. The request should specify the time period for the accounting, which may not exceed six years. Dr. Hetal Shah will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. Right to a Paper Copy of this Notice. You (or your representative) have the right to receive a separate paper copy of this Notice at any time even if you (or your representative) have received this Notice previously. To obtain a separate paper copy, please contact Privacy Officer at 855.998.4900 Right to Breach Notification. You (or your representative) have the right to be notified of any breach of your unsecured health information. Notification of a breach may be delayed or not provided if so required by a law enforcement official. If you are deceased and there is a breach of your health information, the notice will be provided to your next of kin or personal representative if Dr. Hetal Shah knows the identity and address of such individual. CONTACT PERSON Dr. Hetal Shah has designated the Privacy Officer as its contact person for all issues regarding resident privacy and your rights under the Federal privacy standards. If you have any questions or concerns regarding this Notice or your privacy rights, please contact the Privacy Officer at 855.998.4900. You may also write to the Privacy Officerat the following address: Dr. Hetal Shah Attention: Privacy Officer 159 N Jackson Street Suite 105 Milwaukee, WI 53202 COMPLAINTS Dr. Hetal Shah encourages you to express any concerns you may have regarding the privacy of your health information. You will not be retaliated against in any way for expressing your concerns or filing a complaint. You (or your representative) have the right to express complaints to Dr. Hetal Shah or to the Secretary of Health and Human Services if you (or your representative) believe that your privacy rights have been violated. Any complaints to Dr. Hetal Shah may be made by calling the Privacy Officer at 855.998.4900 or by writing to the Privacy Officer at Dr. Hetal Shah, 159 N Jackson Street Suite 105, Milwaukee, WI 53202