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Posted on September 21, 2015June 16, 2016Author adminCategories Hours

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Allied Physicians Group has proudly earned Patient Centered Medical Home (PCMH) Recognition by the National Committee for Quality Assurance (NCQA).

HIPAA Statement

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HIPAA STATEMENT

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.

Dear Patient:

This is not meant to alarm you! It is just the opposite!! We at BEACH PEDIATRICS want to communicate to you that we take te new Federal HIPAA Laws (Health Insurance Portability and Accountability Act) very seriously. These laws were written to protect the confidentiality of your health information. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our office to provide you with quality care and to comply with certain legal requirements. Due to the rapid explosion if the computer and electronic technology in healthcare records, the government has rightfully sought to standardize and protect your information. This notice will tell you about the ways we may use and share medical information about you, describe your rights and certain duties we have regarding the use and disclosure if medical information.

We want you to know about the policies and procedures BEACH PEDIATRICS has developed to make sure your health information will not be shared with anyone who does not require it. In addition, our office is subject to State and Federal law regarding your information and we want you to understand our policy and your rights as our valuable patient.

BEACH PEDIATRICS will use and communicate your health information only to provide treatment, obtain payment, and conduct health care operations. Your information will not be used for any other purposes unless we have been asked for and been given your written permission.

TO PROVIDE TREATMENT: We will use your health information at BEACH PEDIATRICS to provide you with the best pediatric healthcare! This may include administrative and clinical office procedures made to optimize scheduling and coordination of care between the doctors, nurses, lab personnel, reception staff and billing department. We may share this information with physicians you have been referred to, labs, pharmacies or other health care providers involved in your treatment.

TO OBTAIN PAYMENT: We may include your health information with an invoice used to collect payment for treatment you receive at BEACH PEDIATRICS. These insurance claim forms may be filed for you by mail or electronically. Be assured that we will only work with companies who share our commitment to your privacy.

TO CONDUCT HEALTH CARE OPERATIONS: Your health information may be used to measure and improve the quality of pediatric care, evaluate the performance of our staff, in teaching at the office and to get the accreditation, certifications, licenses, and credentials we need to serve you.

IN PATIENT REMINDERS: Because regular pediatric care is important for your child’s health, we remind you if appointments or that it is time for you to contact us for an appointment. Also we may contact you to follow up on your child’s treatment and to inform you of treatment options or services that may be of interest to you or your family. Our communications with you are an integral part of our philosophy at BEACH PEDIATRICS to make sure your children receive the best preventive and curative care possible! This may include newsletters, postcards, telephone pr electronic reminders such as email (unless you choose not to receive these reminders).

ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: We will notify government authorities if we believe a child is a victim of abuse, neglect, or domestic violence. We may share your medical information if is necessary to prevent a serious threat to your child’s health or safety, or the health or safety of others.

PUBLIC HEALTH, NATIONAL SECURITY, MEDICAL RESEARCH: As required by law, we may disclose your medical information to public health or legal authorities in charge of preventing or controlling disease. Health information could be important when the information could lead to control or prevention of an epidemic or the understanding of new side effects of a treatment. In addition, advancing medical knowledge often involves learning from the careful study of the medical histories or prior patients. This study would happen only under the ethical guidance, requirements and approval of an Institutional Review Board.

FOR LAW ENFORCEMENT: As permitted or required by State or Federal law, BEACH PEDIATRICS may disclose your health information to a law enforcement official for certain law enforcement purposes, including if your child is a victim of a crime or in order to report a crime.

FRIENDS AND FAMILY: We may share your health information with those you tell us will be helping you with treatment, home care, medications or payment. We will be sure to ask your permission first. We will also use our professional judgement to make decisions in your child’s best interest about allowing someone to pick up medicine, prescriptions, or medical information for you.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION: Other then stated above, or where required by law, we will not disclose your health information other than with your written authorization. You may revoke that permission in writing at any time.

PATIENT RIGHTS UNDER HIPAA:

RESTRICTIONS: You have the right to request additional restrictions on certain uses and disclosures of your of your child’s health information. BEACH PEDIATRICS will make every effort to honor reasonable restriction preferences.

CONFIDENTIAL COMMUNICATIONS: You have the right to ask that we communicate with you in a certain way. For instance, you may request we communicate your health information privately, through mailed communications that are sealed, or at different locations such as at home or work. Your request must be made in writing. Our office will make every effort to honor your reasonable requests.

INSPECT AND COPY YOUR HEALTH RECORD: You have the right to look at or copy your health information. You must make your request in writing and you will be charged a reasonable fee to duplicate and assemble your copy.

AMEND YOUR HEALTH INFORMATION: You have the right to request that we change your medical information. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe you reason for the change. We may deny your request if we did not create the information you wanted changed, if the information is not part of our records or f the records are determined to be accurate and complete. If we deny your request, we will provide you a written explanation.

DOCUMENTATION OF HEALTH INFORMATION: You have the right to receive a list of how and where we, our business associates shared your medical information for purposes other than treatment, payment, or health care options.

You have the right to obtain a copy of the Notice of Privacy Practices from our office at any time. Stop by or call us and we will mail or make you a copy. You can also get a copy visiting our website at www.beachpediatrics.com. BEACH PEDIATRICS is required by law to maintain the privacy of your health information and to provide you with his notice. We are required to practice the policies and procedures described above, but reserve the right to change the terms of this notice. If we change our privacy practices, we will be sure to notify you with a revised notice. Thank you very much for taking the time to review how we are carefully using your health information. You have the right to question or complain to us or the Secretary of Health and Human Services if you believe your rights have been compromised. We encourage you to express any concerns you may have to us in writing. If you have any questions we want to hear from you.

New Patient Registration

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NEW PATIENT REGISTRATION FORM

For your convienence, print and complete the registration form to expedite new patient registration at your first visit.

Referred By: ________________________

PATIENT REGISTRATION / INFORMATION

Patient Name: ______________________________Date of Birth____________
Address:___________________________________
City_____________________State______________Zip_____________
Telephone#_______________ Cell# _______________
Social Security# (if known)_______________Email address_________________

Allergies No Yes (please list) ________________________________

Emergency Contact_________________Telephone__________________Relation___________

PARENT INFORMATION

Mother’s Name________________________ Father’s Name ___________________________
Address______________________________ Address_________________________________
Telephone # __________________Telephone# ________
Cell/Beeper#__________________________ Cell/Beeper#_____________________________ Employer_____________________________Employer________________________________
Address:________________________ _____Address_________________________________
Social Security #____________________Social Security # _____________________
DOB: ______________________________ DOB:____________________________________
Email_______________________________ Email____________________________________

INSURANCE
PRIMARY SECONDARY N/A YES
Insurance Company____________________ Insurance Company________________
Policy Holder_________________________ Policy Holder_____________________
DOB_____________ ID#_______________ DOB___________ ID#______________
GRP#_______________________________ GRP#____________________________
Employer_____________________________ Employer________________________

INFORMATION AND ASSIGNMENT OF BENEFITS
I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. The authorization may be revoked by either me or my insurance company at anytime in writing.
I hereby authorize BEACH PEDIATRICS to apply for benefits on my behalf for covered services rendered by or ordered by. I request that payment from my insurance company be made directly to my physician with BEACH PEDIATRICS.
I certify that the above information is true and correct and that I have received and understand the HIPAA privacy form.

Date_____________________Signature____________________________________________

New Patient Office Policy Signature Form

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NEW PATIENT OFFICE POLICY SIGNATURE FORM

For your convienence, print and complete form below to expedite new patient registration at your first visit.

Thank you for choosing BEACH PEDIATRICS to care for your child. We welcome you to the practice and look forward to caring for your child. Please take a moment to read the following and sign acknowledgment at the bottom of each page. Be sure to contact your insurance company (if applicable) to inform them that you have chosen BEACH PEDIATRICS for your primary care physician.

Our office complies with HIPAA Regulations, also known as patient privacy rights. This policy is posted throughout the office. If you would like a copy please request one from the reception area.

As you are probably aware, in recent years the number of different health insurance programs has increased at an amazing rate. Even within one company there may be several programs with varying benefits and requirements. Although our staff keeps as up to date as possible there is no way to ensure complete accuracy at all times with each program’s individual provisions. Be sure to contact your insurance directly with any questions regarding your coverage.

Helpful facts to know about your insurance: ☐ Is prior authorization required? ☐ Are you, as the patient or parent required to notify them of hospital admissions or trips to the emergency room? ☐ Is a referral required to see a specialist? ☐ Is there a designated facility to be for diagnostic testing? ☐ Is there a co-pay for services rendered?

There are times that a service is not covered by your insurance and may be offered within the office for a fee. If you prefer to have these services, please let us know and we will advise you of the cost.

Our friendly staff will gladly assist you with any questions or concerns you may have.

Please advise the office of any specific concerns or questions. Thank you.

Date:___________________ Signature____________________________

New Patient Record Release Authorization

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New Patient Record Release Authorization

For your convienence, print and complete the record release form to expedite new patient registration at your first visit.

BEACH PEDIATRICS, PLLC
3227 Long Beach Rd, Ste 1
Oceanside, NY 11572
Phone: 516-897-5000
Fax: 516-431-7519

RECORDS RELEASE AUTHORIZATION

TO: _________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

I HEREBY AUTHORIZE YOU TO RELEASE THE COMPLETE HISTORY AND MEDICAL RECORDS TO:
BEACH PEDIATRICS, PLLC
3227 Long Beach Rd. Ste 1
Oceanside, NY 11572
Tel: 516-897-5000
Fax: 516-431-7519

PATIENT NAME:______________________DOB:__________
ADDRESS:_________________________________________
_________________________________________________

SIGNATURE:_________________________DATE:_________
WITNESS:___________________________DATE:_________

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