Forms & Documents
Privacy Notice (HIPAA).pdfHIPAA NOTICE OF PRIVACY PRACTICES
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Office & Financial Policy.pdfOFFICE AND FINANCIAL POLICIES
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NOTICE OF PRIVACY PRACTICES
In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients with a ‘Notice of Privacy Practice’ statement.
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.
RED MAPLE AUDIOLOGY, LLC is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Treatment
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
Emergencies
We may disclose your health information to notify or assist in notifying a family member or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons
We may disclose your health information to coroners or medical examiners.
Research
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
Public Safety
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies
We may disclose your health information for military, national security, prisoner and government benefits purposes.
Marketing
We may contact you for marketing purposes or fundraising purposes.
Change of Ownership
In the event that RED MAPLE AUDIOLOGY, LLC is sold or merged with another organization, your health information/record will become the property of the new owner.
Your Health Information Rights
You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that RED MAPLE AUDIOLOGY, LLC is not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that RED MAPLE AUDIOLOGY, LLC amend your protected health information. Please be advised, however, that RED MAPLE AUDIOLOGY, LLC is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by RED MAPLE AUDIOLOGY, LLC. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
RED MAPLE AUDIOLOGY, LLC reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, RED MAPLE AUDIOLOGY, LLC is required by law to comply with this Notice. RED MAPLE AUDIOLOGY, LLC is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice, or if you want more information about your privacy rights, please contact us.
Complaints
Complaints about your Privacy rights or how RED MAPLE AUDIOLOGY, LLC has handled your health information should be directed to ASHLEE VANDIVER, AU.D. by calling this office at 207-224-0222. If the OWNER is not available; you may make an appointment for a personal conference in person or by telephone within 2 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
©H.J. Ross Company, Inc. 2002, 2003 HIPAA Interactive-All Rights Reserved FORM 03.501
Office and Financial Policies
Thank you for choosing Red Maple Audiology, LLC (d/b/a Red Maple Speech Pathology) for your audiology and speech pathology needs. We are committed to you and your improved speech, hearing, tinnitus and balance. We also want your experience with us to be a positive and productive one. To that end, we want to take this opportunity to inform our patients and their families of our payment policies. This knowledge will help you be better prepared for your appointment.
Red Maple Audiology, LLC is a participating provider with many insurance companies in the area. We can assist you in determining whether or not we are a participating provider for your insurance plan. You may also contact your insurance company to determine network status as well as to find in-network providers.
Insurance coverage is an agreement between you and your insurance company. We, as healthcare providers, just execute that agreement for you. As a result, it is your responsibility to determine whether or not you have out of network benefits (if Red Maple Audiology, LLC is not a participating provider in your insurance plan), if you require prior authorization or a referral prior to services being provided or if audiology services and/or hearing aids are covered through your plan. It is important to gather this information prior to your appointment with us. Red Maple Audiology, LLC cannot submit a claim to any insurance company if we do not have all required orders, referrals, or prior authorizations on file. They cannot be obtained after the service is provided. If you decline to provide this information to Red Maple Audiology, LLC, you will be responsible for payment of all services rendered in full on the date of your appointment. If you are unsure of your coverage specifics, please bring your member benefits information with you to the appointment.
Insurance companies do not cover, in full, all goods and services. While Red Maple Audiology, LLC will verify coverage specifics with your insurance company as needed, please understand that these are NOT a guarantee of coverage or payment. There may be situations where your insurance company does not cover the specific good or service you are requesting. Red Maple Audiology, LLC commits to providing quality, professional speech and audiologic care to all its patients, regardless of their circumstance. When required and possible, we will work to offer an item or service that is within the limits of your insurance coverage.
It is very important that you inform us within 24 hours of your appointment if you need to cancel or reschedule. While we realize that emergencies do occur, Red Maple Audiology, LLC reserves the right to charge a $105.00 cancellation fee for all no-show appointments or appointments canceled with less than a 24-hour notice.
We understand that sometimes you may be running late to your appointment. Unfortunately, we have patients scheduled throughout the day and may not be able to see you if you arrive more than 10 minutes after your scheduled appointment time. We will try to accommodate you if time allows. Otherwise, we will need for you come back later in the day if a later appointment is available or reschedule to another date and time.
Payment in full is due at the time the services are provided. You are responsible to pay all out of pocket expenses, such as co-payments, co-insurance, deductibles, and the costs of non-covered services on the date the service is provided or the item is dispensed. If that amount is not known at the time of the visit, you must make payment in full upon receipt of an invoice from Red Maple Audiology, LLC following your insurance processing the submitted claim. Late fees will be charged beginning at 30 days. All hearing aid and accessory related charges must be paid on the date you take possession of the aid(s), accessory, or supply.
Red Maple Audiology, LLC accepts payment in the form of cash, checks, and all major credit/debit cards. There will be a $50.00 fee for all bounced or returned checks. Red Maple Audiology, LLC
7 Cobblestone Dr. St. 2
Turner, ME 04282
207-224-0222
It is also the policy of Red Maple Audiology, LLC that we maintain a credit card number on file. This allows us to bill you for an outstanding balance that is not collected within 30 days of the date you were initially billed, while continuing to provide you with care. We will not bill any charge to your credit card without first informing you of this in writing. You then have the right to use an alternate form of payment if you so choose and must notify us within 30 days of receiving your invoice.
It is important that each patient accepts and meets their financial obligations to this practice. Otherwise, we will be unable to provide care to any of our patients. Red Maple Audiology, LLC reserves the right, following 120 days of the initial invoice date, to forward all outstanding balances to either a third-party collection agency and/or small claims court. We also reserve the right to discontinue care or service to patients who have not met their financial obligations to us.
By signing this document, you acknowledge that that you are responsible for payment to Red Maple Audiology, LLC, in full for any and all services rendered that are not covered by insurance, that are subject to your individual deductible, co-insurance, co-payment or any other responsibility as indicated by your insurance coverage. You also acknowledge that failure to make payment to Red Maple Audiology, LLC within 90 days of your initial invoice date will result in your outstanding balance(s) being sent to a third party collection agency and/or small claims court.
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Signature (patient or responsible party) Date
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Printed Name Relationship to patient
Updated 1/2/2023
Red Maple Audiology, LLC
7 Cobblestone Dr. St. 2
Turner, ME 04282
207-224-0222