We are committed to providing you with the best possible medical care. If you have medical insurance, we would like to help you receive the maximum allowable benefits. In order to achieve this goal, we will need your assistance and understanding of our financial policies. Please carefully review this information and sign/initial where indicated.
***** Any changes to personal information must be given to the office immediately*****
ASSIGNMENT: I request that payment of authorized insurance, Medicare, and Medicaid benefits be made payable to Lykos Medical LLC on my behalf for services furnished to me. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. In the event that my account is turned over to a collection agency, I agree to pay all reasonable costs of collection and understand that I may no longer be a patient at this office.
CO-PAY/COINSURANCE/DEDUCTIBLE: I understand that my primary insurance will be billed; billing secondary insurance is a courtesy only and I am ultimately responsible for assigned co-payments, coinsurance and deductible amounts by primary and/or secondary insurance. Tertiary insurance billing remains my responsibility.
RELEASE OF INFORMATION: I authorize the holder of medical information about me to release any and all information to Centers for Medicare and Medicaid Services, its agents, my insurance carrier(s), or other entities as needed to determine these benefits or the benefits for my dependents or myself. If I have health insurance coverage under an HMO, I authorize Lykos Medical LLC to release information concerning my diagnosis and treatment to my primary care or referring physician after each visit.
REQUESTS FOR INFORMATION: Should I receive any requests from my insurance company in regards to my services at this office, I must respond to that correspondence immediately, in order to have the claim processed and paid.
PAYMENTS: Self-pay and previous balance amounts are due when billed. Insurance co-payments are mandated by your insurance company and will be billed after each visit. Patients with insurance claims pending will be sent statements for the full amount due until the account is satisfied. I agree that if the insurance company denies benefits for any reason, I am responsible for the full amount owed for services provided. If I have questions, I understand to contact the office first.
RETURNED CHECKS: I understand and agree to pay a returned check charge of $35.00 for each check that is returned for any reason. I agree to pay the amount of the check plus the service charge within 30 days of receipt of notification.
I have read and agree to the above information and I, the undersigned (patient or POA), am ultimately responsible for the fees. By signing, I consent to be contacted by regular mail, by email or by telephone (including a cell phone number) regarding any matter related to the above referenced account by the creditor, its successors or assigns. This consent includes any updated or additional contact information that I may provide and includes contact that employs auto-dialer technology and/or prerecorded messages.
HIPAA Compliance Policy
Lykos Medical, LLC has adopted this General HIPAA Compliance Policy in order to recognize the requirement to comply with the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”), as amended by the Health Information Technology for Economic and Clinical Health
(“HITECH”) Act of 2009 (Title XIII of division A and Title IV of division B of the American Recovery and Reinvestment Act (“ARRA”) and the HIPAA Omnibus Final Rule (Effective Date: March 26, 2013). We acknowledge that full compliance with the HIPAA Final Rule is required by or before September 23, 2013.
Lykos Medical, LLC hereby acknowledges our duty and responsibility to protect the privacy and security of Individually Identifiable Health Information (“IIHI”) generally, and Protected Health Information (“PHI”) as defined in the HIPAA Regulations, under the regulations implementing HIPAA, other federal and state laws protecting the confidentiality of personal information, and under principles of general and professional ethics. We also acknowledge our duty and responsibility to support and facilitate the timely and unimpeded flow of health information for lawful and appropriate purposes.
Scope of Policy
This policy governs overall HIPAA compliance for Lykos Medical, LLC. All personnel of Lykos Medical, LLC must comply with this policy. Demonstrated competence in the requirements of this policy is an important part of the responsibilities of every member of the workforce.
Officers, agents, employees, contractors, temporary workers, and volunteers must read, understand, and comply with this policy.
Lykos Medical, LLC hereby recognizes its status as a Covered Entity under the definitions contained in the HIPAA regulation.
Lykos Medical, LLC must comply with HIPAA and the HIPAA implementing regulations, in accordance with the requirements at 45 CFR Parts 160 and 164, as amended.
Full compliance with HIPAA is mandatory and failure to comply can bring severe sanctions and penalties. Possible sanctions and penalties include, but are not limited to: civil monetary penalties, criminal penalties including prison sentences, and loss of revenue and reputation from negative publicity.
Full compliance with HIPAA strengthens our ability to meet other compliance obligations, and will support and strengthen our non-HIPAA compliance requirements and efforts.
Full compliance with HIPAA reduces the overall risk of inappropriate uses and disclosures of Protected Health Information (PHI), and reduces the risk of breaches of confidential health data.
The requirements of the HIPAA Administrative Simplification Regulations (including the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules) implement sections 1171-1180 of the Social Security Act (the Act), sections 262 and 264 of the Public Law 111-5, and section 1104 of Public Law 111-148.
Policy Number : 1_Effective Date: 10/4/19 / Last Revised: 10/4/19