Policies of Ben Rapha Medical Clinic PLLC

FINANCIAL RESPONSIBILITY AGREEMENT

I understand that I am financially responsible for all services provided to me by Ben Rapha Medical Clinic PLLC.

We bill for each of our services to provide clinical care. Billable services include, but are not limited to, in-person clinic visits, virtual audio-video visits, phone calls, procedures, remote patient monitoring, and chronic care management.

I agree to pay for all services provided to me by the healthcare provider or clinic at the time services are rendered.

I agree to provide accurate and complete insurance information and to notify the healthcare provider or clinic of any changes in my insurance coverage. I understand that I am responsible for any amounts not covered by my insurance plan.

I acknowledge that I am responsible for paying any co-payments, deductibles, or other out-of-pocket expenses at the time of service. If I am unable to pay for the services provided, I agree to make payment arrangements with the healthcare provider or clinic.

I authorize the healthcare provider or clinic to release any necessary information to my insurance company or any other party responsible for payment of my healthcare services.

I agree to provide the healthcare provider or clinic with updated contact information, including my mailing address, phone number, and email address.

I understand that failure to pay for services provided may result in the healthcare provider or clinic taking legal action to collect payment, and that I may be responsible for any legal fees and expenses incurred by the healthcare provider or clinic in such an action.

I acknowledge that I have read and understand the financial responsibility agreement and agree to comply with its terms.

Patient’s Name: ______________________________________________ Date: __________________________________________

Patient’s Signature: __________________________________________________________________________________________

Appointments/Cancellations

We reserve appointments for you and appreciate choosing Ben Rapha Medical Clinic PLLC.

We’ll remind you of appointments via calls/texts/emails. If contact efforts fail due to mailbox issues or busy lines, we might not reach you.

Kindly extend the courtesy of canceling or rescheduling appointments in advance.

NOTICE OF PRIVACY PRACTICES

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.

OUR OBLIGATIONS

We are committed to maintaining the privacy of your medical information. We are required by law to maintain the privacy of your medical information and to provide you with this notice of our privacy practices.

USES AND DISCLOSURES OF MEDICAL INFORMATION

We may use and disclose your medical information for treatment, payment, and healthcare operations purposes. We may also use and disclose your medical information for other purposes that are permitted or required by law, such as for public health activities or in response to a court order.

YOUR RIGHTS

You have the right to access and receive a copy of your medical information, request amendments to your medical information, and receive an accounting of certain disclosures of your medical information. You also have the right to request that we communicate with you about your medical information in a certain way or at a certain location.

OUR CONTACT INFORMATION

If you have any questions or concerns about this notice or our privacy practices, please contact our privacy officer at the address and phone number listed below:

Ben Rapha Medical Clinic PLLC

4910 Willowbend Blvd, Suite B

Houston, TX 77035

713-701-7802

HIPAA CONSENT

I, understand and acknowledge that Ben Rapha Medical Clinic PLLC is committed to safeguarding the privacy and security of my protected health information (PHI) as required by the Health Insurance Portability and Accountability Act (HIPAA) and its associated regulations.

Authorization for Use and Disclosure of PHI: I authorize Ben Rapha Medical Clinic PLLC to use and disclose my PHI for the purpose of treatment, payment, and healthcare operations. This includes but is not limited to sharing information with other healthcare providers involved in my care, insurance companies for claims processing, and necessary administrative and billing purposes.

Rights Regarding My PHI: I understand that I have the right to:
1. Request restrictions on certain uses and disclosures of my PHI, although Ben Rapha Medical Clinic PLLC may not be obligated to comply with such requests.
2. Access, inspect, and obtain copies of my medical records, subject to legal limitations and any associated fees.
3. Request amendments or corrections to my medical records if I believe they are inaccurate or incomplete.
4. Receive an accounting of disclosures made of my PHI by Ben Rapha Medical Clinic PLLC for purposes other than treatment, payment, or healthcare operations.
5. Request confidential communications, such as alternative methods or locations, to receive communications of my PHI.

Authorization Revocation: I understand that I have the right to revoke this HIPAA consent at any time. However, such revocation will not affect any actions taken by Ben Rapha Medical Clinic PLLC prior to receiving the revocation.

Acknowledgment of Privacy Notice: I have received a copy of the Notice of Privacy Practices from Ben Rapha Medical Clinic PLLC, which explains in detail how my PHI may be used and disclosed and outlines my rights as a patient under HIPAA.

I acknowledge that I have read and understood the above information and voluntarily provide my consent for Ben Rapha Medical Clinic PLLC to use and disclose my PHI as outlined in this HIPAA Consent Form.

Patient’s Name: ______________________________________________ Date: _________________________________________

Patient’s Signature: __________________________________________________________________________________________

COMMUNICATION POLICY

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS & BILLING INFORMATION & REQUESTS FOR FEEDBACK ABOUT YOUR EXPERIENCE VIA:

(Please check one of the following)

Cell phone________ Home phone__________ Text___________ Email_________ All of the above _____________

I AUTHORIZE INFORMATION ABOUT MY HEALTH OR TREATMENT BE CONVEYED VIA:

(Please check one of the following)

Cell phone________ Home phone__________ Text ___________ Email_________ Any of the above ____________

We aim to enhance communication efficiency. Standard rates may apply. Protected health information (PHI) might be shared with third parties following HIPAA for benefit administration. Parties contractually commit to PHI confidentiality. Communications might be added to your medical record.

Patient’s Name: ______________________________________________ Date: _________________________________________

Patient’s Signature: __________________________________________________________________________________________

TELEPHONE CONSUMER PROTECTION ACT (TCPA) OPT IN CONSENT FORM

Our practice uses text messages to communicate with patients for a variety of purposes including appointment confirmations, appointment reminders, billing information, and requests for feedback about your experience. The frequency of messages varies but is generally related to the frequency of your appointments. Mobile message and mobile data rates from your mobile carrier may apply. If you would like to receive these messages by text, you are required to “opt-in” due to recent changes to the Telephone Consumer Protection Act (TCPA). Please note that you can revoke consent to receive these messages at any time. Please take a moment to fill out this consent form indicating your desire to receive these messages in the future.

I give permission to this office to contact me by my cellular device for SMS text messages. By signing, I certify that I am the owner of this cellular device and its user contract. I understand that I can revoke consent at any time or can reply “UNSUBSCRIBE” to a text message to stop receiving text messages at any time.

Patient’s Name: ______________________________________________ Date: _________________________________________

Patient’s Signature: _____________________________________ Patient’s Phone Number: _______________________________

TELEHEALTH & TELEVISIT

This section outlines the terms and conditions of using telehealth/telemedicine services, including the sharing of personal health information, the potential risks and benefits, and the patient’s right to consent or withdraw from such services.

Telehealth/Telemedicine: Telehealth/telemedicine involves electronic communication to share medical information with healthcare providers, including primary care practitioners, specialists, nurses, and clinical care team members, to improve patient care. Family members, caregivers, legal representatives, or guardians may also participate in telehealth/telemedicine services. Patients will receive information about tests, treatments, and procedures, including their benefits, risks, complications, and alternatives, during telehealth/telemedicine visits.

Telehealth/telemedicine services are provided to patients within the state of Texas. Patients are responsible for ensuring they use a safe and secure device with sufficient bandwidth for telehealth/telemedicine consultations. The same financial and other policies are consistently applied to both in-person and telehealth/telemedicine visits.

Types of Information: Telehealth/Telemedicine may involve the transmission of various types of health information, including progress reports, physiological data, videos, pictures, text messages, audio, and other digital forms of data.

Privacy and Confidentiality: Laws protecting the privacy and confidentiality of health information apply to telehealth/telemedicine. Information will only be shared with consent or for treatment, education, billing, and healthcare operations.

Security Measures and Technical Issues: Electronic systems used for telehealth/telemedicine will incorporate security protocols to protect patient identification and data confidentiality. Other individuals may have access to technical support and will adhere to privacy and security policies. There is a risk of technical issues during telehealth sessions, and the patient releases healthcare providers from liability for data breach or loss due to technical failures.

Limited Access to Data: Patients understand that health information provided during telehealth visits may be the primary source of data for evaluation and treatment, as opposed to in-person visits or full medical records.

Right to Withdraw Consent: Patients have the right to withdraw consent for telehealth/telemedicine services at any time without affecting future services or benefits.

I acknowledge that I have read and understood the above information and voluntarily provide my consent for Ben Rapha Medical Clinic PLLC to use Telehealth Services.

Patient’s Name: ______________________________________________ Date: _________________________________________

Patient’s Signature: __________________________________________________________________________________________

PATIENT BILL OF RIGHTS

As a patient receiving medical care, you have the following rights:

The right to respectful and considerate care, free from discrimination based on race, ethnicity, religion, gender, sexual orientation, age, or disability.

The right to receive accurate and easily understood information about your health condition, treatment options, and expected outcomes.

The right to participate in decisions about your care, including the right to refuse treatment.

The right to access your medical records and to request corrections to any inaccuracies.

The right to privacy and confidentiality of your medical information, as protected by federal and state laws.

The right to receive timely and appropriate medical care, regardless of your ability to pay.

The right to receive information about the cost of your care, including itemized bills and explanations of charges.

The right to a safe and clean environment for medical treatment.

The right to file a complaint or appeal with the healthcare provider or a regulatory agency without fear of retaliation.

The right to receive information about how to file a complaint or appeal, including contact information for the appropriate regulatory agency.

We value your rights as a patient and will make every effort to ensure that they are respected and protected.

If you have any questions or concerns about your care, please speak with your healthcare provider or contact the appropriate regulatory agency.

CONSENT TO MEDICAL TREATMENT

I hereby give my informed consent to Dr. Binitha Santhosh and any other healthcare providers who may be involved in my care to provide medical treatment, examinations, procedures, and diagnostic tests as deemed necessary for my health condition.

I understand that the purpose of this medical treatment is to address and manage my health condition, and that there may be alternative treatments or procedures available that have not been recommended to me.

I understand that the healthcare providers involved in my care may need to disclose my protected health information to other healthcare providers involved in my treatment, for the purpose of coordinating my care.

I understand that the healthcare providers will make every effort to maintain the confidentiality of my protected health information, but that there may be certain situations where disclosure may be required by law, such as reporting of communicable diseases or suspected child abuse.

I have had the opportunity to ask questions about the proposed treatment, and my questions have been answered to my satisfaction. I have been given a reasonable explanation of the risks, benefits, and alternatives to the proposed treatment, and I understand the potential consequences of refusing treatment.

I understand that I have the right to revoke this consent at any time, except to the extent that action has been taken in reliance on it.

I certify that I have read and fully understand the above information, and that I have had an opportunity to ask questions about the proposed treatment. I voluntarily consent to receive medical treatment, examinations, procedures, and diagnostic tests as deemed necessary by my healthcare providers.

Patient Signature: __________________________________________________ Date: ____________________

Representative Name: ________________________________________ Relationship: ____________________

Provider Signature: ________________________________________________ Date: ____________________

Ben Rapha Medical Clinic PLLC

4910 Willowbend Blvd, Suite B

Houston, TX 77035

Phone Number: (713) 701-7802

Fax Number: (713) 347-2143

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Policies of Ben Rapha Medical Clinic PLLC

Clinic Address

Clinic Hours

Fax
(713) 347-2143

Policies of Ben Rapha Medical Clinic PLLC

Clinic Address

Clinic Hours

Fax (713) 347-2143

Fax
(713) 347-2143