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Policies

The following policy documents are saved in Microsoft Word DOC file format. If you do not have Microsoft Word installed on your computer, please download the free Microsoft Word Viewer 2003 to be able to view the files.

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Refund Policy

If you have any questions or concerns regarding an online transaction, please contact our billing office at 510.465.0941 ext. 2. You will need to provide us with the following information: Patient account number, date of payment, amount of payment, and a copy of the payment confirmation or transaction detail provided by your financial institution. If there is an overpayment and a refund is due; your card will be credited within 24 hours after speaking to our billing department.

• Download the Refund Policy in DOC File Format

Office Financial Policy

Office Visits

If you have insurance, please bring you insurance card with you. We will bill your insurance. Co-payment and any deductible are due at the time of your visit. Any amount, except the preferred provider discount, not paid by your insurance company will be billed to you for payment.

Please provide your primary insurance information. Please note for most plans we will bill your primary insurance only. If you have Medicare and a supplemental insurance plan, please provide your supplemental insurance card at the time of the visit and we will bill it for you. If you do not provide supplemental information at the time of your visit you will be responsible for the balance due after Medicare pays.

Our office accepts Visa, MasterCard, American Express and Discover Card.

Please Note

There are over 1000 insurance plans in America; therefore, it is impossible for our office to know the covered benefits of your insurance plan. It is the responsibility of the patient to know and understand the policies and benefits of his/her insurance. This includes:

• required referrals obtained and presented prior to service being rendered
• co-payments to be made at the time of service
• covered hospital/laboratory/x-ray procedures
• prior authorization procedures
• current claim address

All Insurances

I request payment of authorized insurance benefits be made to this office for any services furnished to me or on my behalf. I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable to related services.

The patient is ultimately responsible for all professional fees.

• Download the Office Financial Policy in DOC File Format

Cancellation Policy

If you do not keep your scheduled appointment or if you cancel with less than 24 hours notice you may be charged a fee.

Fees for missed appointments or less that 24 hour cancellation are as follows:

• $25.00 - office visit
• $50.00 - office visit with hearing test
• $75.00 - office surgery
• $75.00 - allergy testing

* Please note - 24 hour cancellation notice applies to regular business hours Monday through Friday.

• Download the Cancellation Policy in DOC File Format

Notice of Privacy Practices

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Purpose of this Notice

In the course of doing business, Summit ENT gathers and retains information about our patients. Summit ENT respects the privacy of your personal information and understands the importance of keeping this information confidential and secure. This Notice describes how Summit ENT protects the confidentiality of your personal information that we receive. Summit ENT has implemented policies and procedures in accordance with Federal and State confidentiality and privacy laws to protect your privacy. Summit ENT is obligated to maintain the privacy and confidentiality of your personal information. Summit ENT is also obligated to provide you with notice of its legal obligations to maintain the privacy and confidentiality. These policies and procedures apply to past, present and future Summit ENT patients and past, present and future personal information.

What is “Personal Information”?

“Personal information” is information that identifies who you are and relates to, your past, present, or future physical or mental health or condition, the provision of health care to you, or past, present, or future payment for the provision of health care to you. Personal information does not include information about you that is publicly available, or that is available or reported in summary form, but does not identify who you are.

Types of Uses and Disclosures of Personal Information Made by Summit ENT

Federal laws allows Summit ENT to use and disclose your personal information in order to provide health care services to you as well as to bill and collect payments for the health care services provided to you by participating physicians. Federal laws allow Summit ENT to use and disclose your personal information as necessary in connection with the health care operations of Summit ENT. For example, Summit ENT may use your personal information to request referrals to specialists and to review the quality of care provided by your physician.

Summit ENT may disclose your personal information to health plans or other parties to receive payment for the services provided. Summit ENT might also use your personal information in connection with any grievance or appeal that you file if you are unhappy with the care you have received. Summit ENT may use personal information in connection with disease management programs. Summit ENT may disclose your personal information in connection with court orders or subpoenas. While Federal laws allows Summit ENT physicians to use and disclose your personal information for treatment, payment, and health care operations, the laws requires these providers to obtain written consent to do so. Therefore, the first time you see a Summit ENT physician once the federal rules take effect, the Summit ENT physicians will ask you to sign a consent form allowing the physician to use and disclose your personal information in connection with your treatment, the payment for your treatment, and the physician’s health care operations.

Summit ENT is also allowed by law to use and disclose your personal information without your consent or authorization for the following purposes:

1. When required by law;
2. For public health activities, such as reports about communicable diseases or work-related health issues;
3. In reports about child abuse, domestic violence, or neglect;
4. For health oversight activities, such as reports to governmental agencies that are responsible for licensing physicians or other health care providers;
5. In connection with court proceedings or proceedings before administrative agencies;
6. For law enforcement purposes, such as responding to a court order or subpoena;
7. In reports to coroners, medical examiners, or funeral directors;
8. For tissue or organ donation;
9. For research, with the approval of certain oversight entities; otherwise, use and disclosure of your personal information requires your authorization;
10. To avert a serious threat to the health or safety of a person or of the public;
11. For national security and intelligence activities, including the protection of the President;
12. In connection with services provided under workers’ compensation laws; and
13. For limited marketing purposes when related to you treatment.

Summit ENT may disclose your personal information to your family members who are involved in your care without either your consent or your authorization. However, you must be provided with an opportunity to object prior to disclosure. All other uses and disclosures of your personal information will be made by Summit ENT only with your written authorization.

How We Protect Personal Information

Summit ENT restricts access to your personal information to those who need access in order to provide services. We have established and maintain appropriate physical, electronic and procedural safeguards to protect your personal information against unauthorized disclosure. We have established a training program that Summit ENT employees must complete and update annually. We have also established a Privacy Officer, who has overall responsibility for developing, training and overseeing the implementation and enforcement of policies and procedures to safeguard your personal information against inappropriate access, use and disclosure, consistent with applicable state and federal laws.

Authorizations

If an authorization is needed, Summit ENT will provide you with an authorization form for you or your personal representative to complete. When you receive the form, please fill it out and send to the following address:

Your Individual Rights

Access to Personal Information

As a matter of federal and state laws, you have the right to review and copy your personal information received and retained by Summit ENT. If you desire to access to your personal information, you must notify Summit ENT in writing. We will respond to your request and provide a time and place, within normal business operating hours, for your inspection of the personal information Summit ENT has in its possession. If you request a copy of the information held by Summit ENT, a copy can be provided. We reserve the right to charge a reasonable administrative fee for copying your personal information, as allowed by applicable law.

Right to Amend Personal Information

State and federal law provided you the right to request an accounting of all disclosures of your personal information made by Summit ENT that are not directly related to your treatment , payment for your treatment, or Summit ENT health care operations as outlined above. You may request an accounting in writing. Summit ENT will provide this accounting to you within a reasonable period of time after your request and in accordance with the policies and procedures established by Summit ENT.

Right to Receive this Notice

You have the right to request and receive a copy of this Notice in written or electronic form. You may contact Summit ENT for a copy, and one will be provided to you at no charge.

Right to Request Restriction on Disclosure of Personal Information

State and federal laws permits you to request restrictions on the use and disclosure of your personal information by Summit ENT. Summit ENT reserves the right to accept or reject your request for restriction. All requests must be made in writing. Upon receipt, Summit ENT will review the request and notify you of its decision to either accept or reject the request. Even if Summit ENT agrees to honor your request to restrict Summit ENT uses and disclosure of your personal information, Summit ENT may cease to honor that restriction without your consent. In that event, Summit ENT will continue to honor the request for a restriction in connection with all personal information, which Summit ENT received or created prior to termination of the restriction. However, Summit ENT will not be obligated to honor the restriction after it provides you notice that it will cease to do so. If you agree to terminate, then Summit ENT may use and disclose all of your personal information in its possession in accordance with applicable law. All requests for restrictions which are agreed to by Summit ENT will be made part of your personal information and be made available for your review upon proper request.

Right to Confidential Communications

You have the right to request that Summit ENT provide your personal information to you in a confidential manner. For example, you may request that Summit ENT send your personal information by alternate means or to an alternate address, such as by telephone to a different telephone number or to an office address rather than your home address. Also, you may, for example, request that your personal information be sent in a sealed envelope rather that on a postcard.

Right to Complain

Summit ENT is obligated to comply with the privacy set forth in this Notice. If you believe that Summit ENT has violated this privacy policy, you have the right to file a complaint with Summit ENT Medical Associates, your health plan, The California Department of Managed Care or the United States Department of Health and Human Services, Office of Civil Rights.

Contacting Summit ENT Regarding Your Rights

If you should have any questions regarding your rights or wish to make any of the above requests or complaints you should direct you inquiries to:

Rights Reserved by Summit ENT

Summit ENT reserves all the rights expressed above. Summit ENT further reserves the right to amend or change the terms of this Notice at any time and to make the provisions of the new notice effective for all personal information we maintain. You may request updates to this notice, and by contacting Summit ENT at the address above.

Effective Date

The effective date of this Notice is: April 14, 2003

• Download the Notice of Privacy Practices Policy in DOC File Format