We are required by applicable federal and state laws to maintain the privacy of your protected health information. We must follow the privacy practices described in this notice while it is in effect. We reserve the right to change our privacy practices and update this policy as needed. Any changes will apply to information we already have, as well as new information we receive.

We collect personal health information about you, including:

• Demographic information (name, address, phone number, email, etc.)
• Medical history and physical exam findings
• Test results and diagnoses
• Treatment plans and procedures
• Insurance and billing information
• Communications between you and our healthcare team

Your health information may be used and disclosed for:

• Treatment: Providing, coordinating, or managing your healthcare
• Payment: Billing and collecting payment for your healthcare services
• Healthcare Operations: Conducting quality assessment, employee review, training, and business activities
• Appointment Reminders and Health-Related Communications
• Legal Requirements and Public Health Activities

We maintain physical, electronic, and procedural safeguards that comply with federal regulations to protect your personal health information. These measures include:

• Secured electronic medical record systems
• Encrypted communication channels
• Limited access to patient information based on job role
• Staff training on privacy and security procedures
• Secure disposal of medical records when appropriate

Under HIPAA, you have the following rights regarding your health information:

• Right to review and obtain copies of your medical records
• Right to request corrections to your information
• Right to receive an accounting of disclosures
• Right to request restrictions on information sharing
• Right to request confidential communications
• Right to be notified of any breach of unsecured protected health information

If you have questions about our privacy practices or believe your privacy rights have been violated, please contact:

Fremont Foot and Ankle
604 S 9th St
Cañon City, Colorado 81212

Phone: (719) 275-1037
Fax: (877) 807-4835

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

We are a participating Medicare provider. Medicare as well as your secondary insurance (if any) will be billed for you. However; that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not yet been met. You are also responsible for any copayments, which are usually 20% of the allowed amount for an item or service.

All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment/deductible at each visit.

Please be aware that some - and perhaps all - of the services you receive may be uncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If required, obtaining the proper referral from your Primary Care Physician is your responsibility. Patients presenting to our office without a valid referral will be asked to pay in full. This payment will be held for 48 hours and will become non refundable if the proper referral is not obtained by then.

We will submit your claims and assist you in any way we reasonably can to help get your claims paid. 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. Your insurance benefit is a contract between you and your insurance company.

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

We accept the following payment methods: Cash, Check, VISA/Mastercard, and Care Credit. An additional $35.00 will be added to your statement if the check is returned for insufficient funds. In the event that your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance.

Invoices are sent out every 30 days. Your prompt payment will assist us in keeping the cost of healthcare down. If your account is over 60 days past due, you will receive a letter requesting immediate payment. A re-billing charge of $10.00 per month will accrue on all accounts over 60 days past due. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to small claims court and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative podiatric care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Missed Appointments: Our policy is to charge $35.00 for missed appointments not canceled within a reasonable amount of time (24 HOURS) or for an understandable reason. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

In-Office Product Sales: Our in office products that are for sale by their very nature are not returnable. All sales are final.

Medical Information: By signing this consent form you are agreeing that your provider at Fremont Foot and Ankle may request/access some medical information that may include but not limited to your prescription medication history, imaging results/reports, lab orders/results and other pertinent information from other healthcare providers and/or pharmacies that may be required to ensure proper safety and optimized your medical care. This information will be used for medical decision making and treatment.

Treatment Agreement: I promise full cooperation with my treating physician whether by surgical or non-surgical means. I understand that if I do not follow my doctor's instructions concerning my care and treatment, including any necessary physical therapy or medications, the outcome of my care and treatment could be put into jeopardy and less than optimal results may occur.

Notice of Privacy Practices (HIPAA): I acknowledge that I was provided a copy of the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. The Foot and Ankle Specialists of Colorado HIPAA rights are also posted in www.fremontfootandankle.com

Authorization of Payment: I hereby assign all Medical benefits directly to Foot and Ankle Specialists of Colorado, PLLC for the payment of any services rendered. I also authorized release of medical records necessary to process my health claims. I fully understand that in the event my insurance company does not pay for the services I received, I will be financially responsible for payment.

We are dedicated to providing the best possible care and service to you and regard your complete understanding of our policies as an essential element of your care and treatment. Our fees are representative of the usual and customary charges for our area. If you have any questions, please discuss them with our front office staff or supervisor.

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the 21st Century Cures Act of 2016, patients have the right to access their electronic health information and are encouraged to keep their records up to date. These laws emphasize the importance of patient engagement in the management of their health data and ensure that you, as a patient, have the ability to review, amend, and supplement your electronic medical records as needed.

Your health record is used by healthcare providers to make decisions about your care. An accurate and complete record helps us:

• Provide timely, effective care: Ensures that we have a full understanding of your health needs.
• Avoid errors: Helps prevent potentially harmful mistakes that can arise from outdated or incomplete information.
• Improve health outcomes: Ensures that you receive the most appropriate treatments and interventions based on your current health status.

By signing this document you agree and understand that you are responsible for ensuring that the medical information you provide to Fremont Foot and Ankle is accurate, complete and up-to-date. You also understand that at Fremont Foot and Ankle you are responsible for providing this information through the patient portal. You have the right to review and amend your health record through the patient portal at any time.

Thank you for being an active participant in your healthcare. By keeping your health record current, you are helping us provide you with the best possible medical care.