END USER AGREEMENT
PLEASE READ THE ENTIRE AGREEMENT BELOW AND INDICATE YOUR ACCEPTANCE BY RETURNING BACK TO THE CHECK OUT PROCESS AND CLICKING THE CHECK BOX NEXT TO "I agree with the terms and conditions" ABOVE THE CHECK OUT BUTTON. IF YOU DO NOT AGREE TO THESE TERMS AND CONDITIONS, DO NOT USE THE SERVICES.
Welcome to the IT IS ENT, PLLC virtual visit Service (the “Service”), which is operated by IT IS ENT, PLLC, DBA Capital Otolaryngology. (“IT IS ENT,” “we” or “us”).
If you do not agree to these terms and conditions, you are not authorized to access or use this website.
Please print and keep a copy of this Agreement. IT IS ENT may, from time to time, change the terms of this Agreement. It is your responsibility to review these terms each time you use this website.
IMPORTANT INFORMATION ABOUT YOUR USE OF THE SERVICE
DO NOT USE THIS SITE FOR EMERGENCY MEDICAL NEEDS. If you experience a medical emergency, call 911 immediately.
You hereby certify that you are the person with a legal name used during the check out process with a full financial responsibility for transactions being made using this website. You acknowledge that your ability to access and use the Service is conditioned upon the truthfulness of this certification and that the providers you access are relying upon this certification in order to interact with you. In the event that your certification is inaccurate, you agree to indemnify IT IS ENT and the providers you interact with from any resulting damages, costs or claims.
Your personal information will be stored in a secure manner. We or our licensors have implemented a variety of commercially standard encryption and security technologies and procedures to protect your personal information which is stored in our computer systems from unauthorized access. We or our licensors also maintain standard physical and electronic procedural safeguards that limit access to your personal information to our employees, our licensors’ employees, and people working on our behalf and under confidentiality agreements, who, through the course of standard business activities, need to access your personal information.
Access to the Service is enabled only by usernames and passwords. You should maintain your username and password in strict confidence. In no event should you share your username or password with any third party or allow another person to access the Service using your username and password. Please notify us if you have any reason to believe that your username or password has been lost or compromised or misused in any way. You are fully and solely responsible for any and all use of the Service using your username and password. We reserve the right to revoke or deactivate your username and password at any time.
You agree not to access or use the Service in an unlawful way or for an unlawful or illegitimate purpose or in any manner that contravenes this Agreement. You shall not post, use, store or transmit (a) a message or information under a false name; (b) information that is unlawful, libelous, defamatory, obscene, fraudulent, predatory of minors, harassing, threatening or hateful to any person; or (c) information that infringes or violates any of the intellectual property rights of others or the privacy or publicity rights of others. You shall not attempt to disrupt the operation of the Service by any method, including through use of viruses, Trojan horses, worms, time bombs, denial of service attacks, flooding or spamming. You shall not use the Service in any manner that could damage, disable or impair the Service. You shall not attempt to gain unauthorized access to any user accounts or computer systems or networks, through hacking, password mining or any other means. You shall not use any robot, scraper or other means to access the Service for any purpose.
OPERATION AND RECORD RETENTION
IT IS ENT reserves complete and sole discretion with respect to the operation of the Service. IT IS ENT may, among other things withdraw, suspend or discontinue any functionality or feature of the Service. Subject to applicable law, IT IS ENT reserves the right to maintain, delete or destroy all communications and materials posted or uploaded to the Service pursuant to its internal record retention and/or destruction policies.
Areas of the Service or IT IS ENT’s webpages may contain links to other web sites. Please note that when you click on any of these links, you are entering another web site for which we have no responsibility or control. The inclusion of any link does not imply affiliation, endorsement or adoption by us of the linked site or any medical or other information contained therein. We encourage you to read the terms and conditions, data-gathering practices and privacy policies of all linked sites as they may materially differ from ours. You agree that we shall not be responsible for any loss or damage of any sort incurred as a result of any such links or as the result of the presence of such links on this site. It is up to you to take precautions to ensure that whatever linked material you select is free of items such as viruses, worms, Trojan horses and other destructive items.
All of the content available on or through the Service (“Content”) is the property of IT IS ENT or its licensors and is protected by copyright, trademark, patent, trade secret and other intellectual property law. We give you permission to display, download, store and print the Content only for your personal, non-commercial use. You agree not to reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, or circulate the Content received through the Service to anyone, including but not limited to others in your organization. All software and accompanying documentation made available for download from the Service is the copyrighted work of IT IS ENT or its licensors. Any copy made of information obtained through the Service must include all applicable copyright notices.
All IT IS ENT trade and service names, including, but not limited to “IT IS ENT” and “IT IS OTO”, are trademarks of IT IS ENT, PLLC or its licensors. All other brands and names are the property of their respective owners. Nothing contained in the Service should be construed as granting any license or right to use any trademark displayed on this site without the express written permission of IT IS ENT or such third-party that may own the trademark.
Subject to the terms of this Agreement, IT IS ENT hereby grants you a limited, revocable, non-transferable and non-exclusive license to use the software, network facilities, Content and documentation on and in the Service to the extent, and only to the extent, necessary to access and use the Service.
The license granted herein does not permit you, and you agree not to: (a) modify, translate, reverse engineer, disassemble, decompile or create derivative works of the Service or allow a third party, whether directly or indirectly (including, but not limited to the direct or indirect use of wizards, agents, bots, or other utilities), to modify, translate, reverse engineer, disassemble, decompile or create derivative works of the Service; or (b) transfer, distribute, sell, lease, rent, disclose or provide access to the Service to any third party or use the Service to provide service bureau, time sharing or other services to third parties.
ACCESS TO THE SERVICE AND THE INFORMATION CONTAINED THEREIN IS PROVIDED “AS IS” AND “AS AVAILABLE” WITHOUT ANY WARRANTY OF ANY KIND, EXPRESS OR IMPLIED. TO THE FULLEST EXTENT PERMISSIBLE PURSUANT TO APPLICABLE LAW, MEDSTAR DISCLAIMS ALL WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO ANY IMPLIED WARRANTIES OF TITLE, MERCHANTIBILITY, FITNESS FOR A PARTICULAR PURPOSE OR NON-INFRINGEMENT.
WITHOUT LIMITING THE FOREGOING, MEDSTAR DOES NOT WARRANT THAT ACCESS TO THE SERVICE WILL BE UNINTERRUPTED OR ERROR-FREE, OR THAT DEFECTS, IF ANY, WILL BE CORRECTED; NOR DOES MEDSTAR MAKE ANY REPRESENTATIONS ABOUT THE ACCURACY, RELIABILITY, CURRENCY, QUALITY, COMPLETENESS, USEFULNESS, PERFORMANCE, SECURITY, LEGALITY OR SUITABILITY OF THE SERVICE OR ANY OF THE INFORMATION CONTAINED THEREIN. YOU EXPRESSLY AGREE THAT YOUR USE OF THE SERVICE AND YOUR RELIANCE UPON ANY OF ITS CONTENTS IS AT YOUR SOLE RISK.
YOU SHALL BE SOLELY AND FULLY RESPONSIBLE FOR ANY DAMAGE TO THE SERVICE OR ANY COMPUTER SYSTEM, ANY LOSS OF DATA, OR ANY IMPROPER USE OR DISCLOSURE OF INFORMATION ON THE SERVICE CAUSED BY YOU OR ANY PERSON USING YOUR USERNAME OR PASSWORD. MEDSTAR CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR ANY LOSS, DAMAGES OR LIABILITIES ARISING FROM THE FAILURE OF ANY TELECOMMUNICATIONS INFRASTRUCTURE, OR THE INTERNET OR FOR YOUR MISUSE OF ANY PROTECTED HEALTH INFORMATION, ADVICE, IDEAS, INFORMATION, INSTRUCTIONS OR GUIDELINES ACCESSED THROUGH THE SERVICE.
LIMITATIONS OF LIABILITY
IN THE EVENT OF ANY PROBLEM WITH THE SERVICE OR ANY OF ITS CONTENT, YOU AGREE THAT YOUR SOLE REMEDY IS TO CEASE USING THE SERVICE. UNDER NO CIRCUMSTANCES SHALL MEDSTAR, ANY MEDSTAR LICENSOR OR SUPPLIER, OR ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE SERVICE BE LIABLE IN ANY WAY FOR YOUR USE OF THE SERVICE OR ANY OF ITS CONTENT, INCLUDING, BUT NOT LIMITED TO, ANY ERRORS OR OMISSIONS IN ANY CONTENT, ANY INFRINGEMENT BY ANY CONTENT OF THE INTELLECTUAL PROPERTY RIGHTS OR OTHER RIGHTS OF THIRD PARTIES, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF ANY CONTENT.
UNDER NO CIRCUMSTANCES SHALL MEDSTAR, ITS LICENSORS OR SUPPLIERS OR ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE SERVICE, BE LIABLE FOR ANY PUNITIVE, EXEMPLARY, CONSEQUENTIAL, INCIDENTAL, INDIRECT OR SPECIAL DAMAGES (INCLUDING, WITHOUT LIMITATION, ANY PERSONAL INJURY, LOST PROFITS, BUSINESS INTERRUPTION, LOSS OF PROGRAMS OR OTHER DATA ON YOUR COMPUTER OR OTHERWISE) ARISING FROM OR IN CONNECTION WITH YOUR USE OF THE SERVICE, WHETHER UNDER A THEORY OF BREACH OF CONTRACT, NEGLIGENCE, STRICT LIABILITY, MALPRACTICE OR OTHERWISE, EVEN IF WE OR THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
The Service is designed for and intended for users in the United States. IT IS ENT makes no representation that the information and services provided on the Service are applicable to, appropriate for, or available to users in locations outside the United States. Accessing the Service from territories where the content is illegal is prohibited. If you choose to access the site from a location outside the U.S., you do so on your own initiative and you are responsible for compliance with local laws.
IT IS ENT may suspend or terminate your access to the Service at any time, for any reason or for no reason at all. IT IS ENT has the right (but not the obligation) to refuse to provide access to the Service to any person, agency or organization at any time, for any reason or for no reason at all, in our sole discretion. IT IS ENT reserves the right to change, suspend, or discontinue all or part of the Service, temporarily or permanently, without prior notice. IT IS ENT reserves the right to delete or change any username or password at any time, for any reason or for no reason at all.
Without limiting the generality or effect of other provisions of this Agreement, as a condition of use, you agree to indemnify, hold harmless, and defend IT IS ENT and its parents, subsidiaries, affiliates, licensors, suppliers and their officers, directors, affiliates, subcontractors, agents and employees (collectively, “Indemnified Parties” and each, individually, an “Indemnified Party”) against all costs, expenses, liabilities and damages (including reasonable attorney’s fees) incurred by any Indemnified Party in connection with any third party claims arising out of: (i) your failure to comply with any applicable laws and regulations; and (ii) your breach of any of its obligations set forth in this Agreement. You shall not settle any such claim without the written consent of the applicable Indemnified Party.
ELECTRONIC CONTRACTING AND NOTICES
Your assent to the terms of this Agreement by clicking the “AGREE” checkbox. You agree that we may send to you in electronic form any privacy or other notices, disclosures, reports, documents, communications or other records regarding the services (collectively, “Notices”). We can send you electronic Notices (1) to the e-mail address that you provided to us during registration, or (2) by posting the Notice on the Service or otherwise through our site. The delivery of any Notice from us is effective when sent by us, regardless of whether you read the Notice when you receive it or whether you actually receive the delivery. You can withdraw your consent to receive Notices electronically by canceling or discontinuing your use of the applicable service.
NOTICE OF PRIVACY PRACTICES
By clicking the “AGREE” button you acknowledge that you are consenting to receiving care via the Service. The scope of care will be at the sole discretion of the healthcare provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. The healthcare provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via the Service. The Service respects and upholds patient confidentiality with respect to protected health information as outlined by the Health Insurance Portability and Accountability Act (“HIPAA”), and, subject to HIPAA regulations, will obtain express patient consent prior to sharing any patient-identifiable information to a third party for purposes other than treatment, payment or health care operations. In addition, by clicking the “AGREE” button you are authorizing OCN to release your contact information to IT IS ENT solely in order for IT IS ENT to provide you with marketing materials promoting the Service. You may opt out of receiving such marketing materials by contacting us at firstname.lastname@example.org.
Telemedicine involves the use of electronic communications to enable health care providers at sites remote from patients to provide consultative services. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g., medical records, data from medical devices).
The communications systems used will incorporate network and software security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. An encounter summary will be provided to the patient at the end of each encounter which may be kept for the patient’s records and may be shared with the patient’s local primary care or other provider, as appropriate.
Anticipated Benefits of Telemedicine:
- Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.
- More efficient medical evaluation and management.
Possible Risks of Telemedicine:
As with any medical procedure, there are potential risks associated with the use of telemedicine. IT IS ENT believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:
- Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment.
- Security protocols could fail, causing a breach of privacy of personal medical information.
- Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine; I have received the IT IS ENT Notice of Privacy Practices which explains these issues in greater detail.
- I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes.
- I further understand that my healthcare information may be shared in the following circumstances:
- When a valid court order is issued for medical records.
- Reporting suspected abuse, neglect, or domestic violence.
- Preventing or reducing a serious threat to anyone’s health or safety.
Patient Consent to the Use of Telemedicine
I understand that this authorization to bill my credit card or debit card (including any other IT IS ENT accepted payment mechanism) will remain in effect until I cancel it in writing, and I agree to notify IT IS ENT in writing of any changes in my account information. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that IT IS ENT may at its discretion attempt to process the charge again at any time within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the co-payment required by my health plan.
Please refer to Appendix B and ask us any questions you may have at email@example.com. A copy will be provided to you upon request.
This Agreement shall be governed by the laws of the State of Maryland without regard to its rules on conflicts or choice of law. You hereby consent to the exclusive jurisdiction of the courts of the State of Virginia for the resolution of any dispute based upon or relating to this Agreement. This Agreement constitutes the sole Agreement between you and IT IS ENT relating to your use and our provision of the Service and the subject matter hereof, and no representations, statements or inducements, oral or written, not contained in this Agreement shall bind either you or IT IS ENT. Any of the terms of this Agreement which are determined to be invalid or unenforceable shall be ineffective to the extent of such invalidity or unenforceability, without rendering invalid or unenforceable any of the remaining terms of this Agreement or affecting the validity or enforceability of the Agreement as a whole. Failure to insist on performance of any of the terms of the Agreement will not operate as a waiver of any subsequent default. No waiver by IT IS ENT of any right under this Agreement will be deemed to be either a waiver of any other right or provision or a waiver of that same right or provision at any other time. You may not assign, transfer or delegate your rights or obligations hereunder, in whole or in part. This Agreement shall be binding upon and inure to the benefit of each of the parties and the parties’ respective successors and permitted assigns. Except as otherwise specifically provided herein, this Agreement may not be modified, supplemented, qualified, or interpreted except in writing signed by the parties.
A printed version of this Agreement and of any related notice given in electronic form shall be admissible in judicial or administrative proceedings based upon or relating to this Agreement to the same extent and subject to the same conditions as other business documents and records originally generated and maintained in printed form.
I hereby certify that I am located in my current state (indicate on next page), and agree to only interact with a Provider through IT IS ENT’s Virtual visit while I am present in that state. I acknowledge that my ability to access and use these services is conditional upon the truthfulness of the certifications I make at the time of accessing a Provider, and that the Providers I access are relying upon this certification in order to interact with me.
I hereby certify that I am at least 18 years of age and am qualified under the laws of my state to make medical decisions on my own behalf. I acknowledge that my ability to access and use the IT IS ENT’s Virtual visit system and information is conditional upon the truthfulness of my certification of age.
Appendix A : NOTICE OF PRIVACY PRACTICES – IT IS ENT, PLLC
For more information, contact:
IT IS ENT, PLLC (the “Provider”)
P.O. BOX 30904
ALEXANDRIA, VA 22310
Your Information. Your Rights. Our Responsibilities.
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.
You have the right to:
- Get a copy of your electronic medical record
- Correct your electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide mental health care
- Market our services and sell your information
Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
Continue reading for more detailed information . . .
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone or email) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Upon request, we will provide you with a paper copy promptly.
Choose someone to act for you
- 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.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us.
- 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.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
You have the right to tell us to:
- Share information with your family, close friends, or others involved in your care (or not to)
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In addition, mental health records may be withheld from you if your provider determines that disclosure would be detrimental to you.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and to contact you when necessary. Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it upon request.
- We never sell identifiable personal information.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind, and your updated instructions will apply to any future requests for information that we receive.
- Federal and state laws may place additional limitations on the disclosure of your health information related to drug or alcohol abuse treatment programs, sexually transmitted diseases, genetic information, or mental health treatment programs. When required by law, we will obtain your authorization before releasing this type of information.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.
Patient Bill of Rights
Many states have adopted a patient bill of rights applicable to patients of physicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to the Service is provided to you here on behalf of OCN. Please note that it includes patient responsibilities as well.
A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.
A patient has the right to know who is providing medical services and who is responsible for his or her care.
A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
A patient has the right to know what rules and regulations apply to his or her conduct.
A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.
A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.
A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.
A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.
A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
A patient is responsible for reporting unexpected changes in his or her condition to the Provider.
A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
A patient is responsible for following the treatment plan recommended by the Provider.
A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.
State Specific Notifications (See Below For State Specific Mental Health Notifications)
FOR VIRGINIA RESIDENTS
We are happy to maintain your records while you are an active patient or to transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. We consider patients inactive if they either ask to have their records transferred or they have not been seen in any of our offices for six years. Our policy is to destroy inactive medical records in accordance with the Virginia Department of Health Professions regulations.
These regulations (18VAC85-20-26) state that practitioners must maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:
- Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;
- Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or
- Records that are required by contractual obligation or federal law to be maintained for a longer period of time.
Practitioners must post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records can only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. For more information from the Virginia Department of Health Professions, go to www.dhp.virginia.gov/Medicine.
Appendix B : PAYMENT POLICY
- Insurance. It Is ENT, Pllc does not participate in insurance plans, including Medicare/Medicaid. Therefore, payment in full is expected for all services provided by Estelle Yoo, MD upon the receipt of your bill. Credit cards (Visa, MasterCard, American Express, Discover) can be processed online or via phone by calling (571)447-9136. Once the bill has been paid in full, an itemized invoice will then be generated and sent to you to initiate further insurance filing. Knowing your insurance benefits is your responsibility. Any out-of-network coverage claim will need to be filed by you to your insurance company for a subsequent reimbursement. Please contact your insurance company with any questions you may have regarding your coverage.
- Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered necessary by Medicare/Medicaid or other insurers such as cosmetic only procedures. You must pay for these services in full.
- Claims submission. If you have an out-of-network coverage, your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. You must pay for the services rendered in full. It is your prerogative to pursue further claims with your insurance company to get reimbursed subsequently. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
- Nonpayment. If your account is over 60 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be that you have 30 days to find alternative medical care.
Thank you for understanding our payment policy. Please let us know if you have any questions or concerns at firstname.lastname@example.org