Lincoln Park - Fasting Lab Draw - Medical Weight Loss Program
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Provider Name:
Boost Oliver
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Step 6.
Patient Information
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FINANCIAL RESPONSIBILITY POLICY I acknowledge and understand that payment for services is due at the time of service. Raden Wellness accepts all major credit cards for all transactions. I agree to ensure a form of payment is updated promptly should the current form of payment expire or become invalid. Additionally, I agree to ensure a valid form of payment is available prior to my scheduled appointment(s). I authorize Raden Wellness/Raden IV Center to process payment utilizing the billing information on file following each appointment and that prior notification to the patient is not required to do so. I understand that copies of invoices and receipts are generally automatically updated in the Patient Portal following payment, but that I may also contact Raden Wellness and request an invoice if necessary.
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Patient Information
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CANCELLATION AND RESCHEDULING POLICY I agree to make every effort to arrive on time to my scheduled appointment(s), and that I understand that no-shows, last minute cancellations, and arriving for my appointment more than 15 minutes after the scheduled time increases the difficulty for other patients to receive treatment. I agree to arrive within 15 minutes of my scheduled appointment time, and that should I arrive significantly before or after my appointment I may not be seen. In the event I need to cancel or reschedule my appointment, I agree to make every effort to do so prior to 24 hours before my appointment. I acknowledge that I may submit a cancellation request via the Patient Portal or by phone (and voicemail in the event the office is closed or a team member is unavailable). I understand that if I arrive more than 15 minutes past my scheduled appointment time without notifying the office my appointment may be cancelled and/or rescheduled for the next available time. I understand that any no-shows, cancellations, or rescheduled appointments within 24 hours of the scheduled appointment time will be charged a No-Show/Late Cancellation fee totaling the cost of the scheduled appointment.
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Step 6.
Patient Information
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OFFICE POLICY STATEMENT This agreement document contains important information about our professional services and business policies. It also contains summarized information regarding HIPPA, the Health Insurance Portability and Accountability Act, a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI), which is used for the purpose of treatment, payment, and healthcare operations. HIPPA requires that we provide you with the Notice of Privacy Practices, which is enclosed within this statement. Your signature is required by law on the agreement as well as the Acknowledgement of Receipt document, and you agree that your signature below completes this requirement. Although these documents may be long a complex at times, it is important that patients review them carefully. When this document is signed, the agreement has been agreed upon by both parties. Patients may revoke the agreement in writing at any time. The revocation will be binding unless action has been taken in reliance of it, if there are obligations imposed on Raden Wellness by your health insurance provider to process or substantiate claims under your policy, or if you have not satisfied any financial obligation you have incurred. HOW OFTEN CAN I EXPECT TO HAVE AN APPOINTMENT? Appointment frequency varies significantly depending upon each patient's symptoms, goals, and specific needs. Practitioners recommend appointments in the manner they will best benefit the patient's health and wellness, in addition to any legal requirements with regards to medical oversight. Appointments are typically 15 minutes or longer. Occasionally, in the event that families are involved, extended sessions may be scheduled. Every effort will be made to schedule appointments at times that are convenient for the patient. HOW MIGHT I REACH YOU IF/WHEN NECESSARY? Although face-to-face conversations are ideal, there may be instances in which phone calls or portal messages are preferred. Please note that portal messaging will be limited to answering questions regarding side effects, clarification, or general questions. Any communication that requires clinical decision-making will be best addressed during an appointment. In the event an appointment needs to be cancelled and/or rescheduled, please contact our office via phone or portal message. In the event you are looking to cancel or reschedule your appointment within the 24-hours prior to your appointment, please contact our office by phone. Voicemails are acceptable in the event a team member is not available. WHAT HAPPENS IF AN APPOINTMENT IS MISSED? Adherence to your recommended treatment plan and arriving on time is an indication of your commitment to the therapeutic process and your overall health and well-being. Late cancellations or no-shows frequently prevent other patients needing care from receiving it. Exceptions with regards to the cancellation fee may be made in emergency situations, however, that determination is at the discretion of Raden Wellness management. HOW CONFIDENTIAL ARE SESSIONS? The various laws of the State of Illinois ensure that conversations between patients and practitioners are held in the strictest confidence. No information regarding you or the topics discussed with your practitioner will be shared with anyone without your permission in writing, except as noted below: Practitioners are obligated to share informationn provided to them in confidence in the event they have reason to believe that a patient is: 1) likely to inflict bodily harm on someone; 2) likely to harm themselves; 3) suspected of or involved in child or elder abuse; 4) or psychological decompensating of an individual to the point they can no longer care for themselves. A court may demand a clinician/practitioner testify when there is just cause as deemed by the judge. Other legal proceedings (i.e. worker's compensation claims, criminal proceedings, competency hearings, etc.) as well as your own submission of a claim to your insurance carrier may require a clinician/practitioner to release information with a release signed by the patient. WHAT TO DO IN THE EVENT OF AN EMERGENCY In the event of a life-threatening emergency contact 911 or go to your nearest emergency room. In the event you are experiencing non-life threatening symptoms, please feel free to contact our office and we will be happy to provide recommendations when/if possible and applicable. Please contact your family practitioner or primary care physician in the event we are unable to answer or return your call as quickly as you feel is necessary. WHEN IS IT TIME TO END TREATMENT? At Raden Wellness, we believe patients should be included and empowered to manage their health and treatment when possible. We encourage patients to feel comfortable in requesting duration information when discussing their treatment plan with practitioners. Patients often feel intuitively when it may be time to "move on." However, there are instances in which patients decide to end treatment prematurely as they are experiencing relief of their symptoms, however, the underlying issues are not completely resolved. Alternatively, there are instances in which patients choose to discontinue treatment as coping with the symptoms that originally brought them to Raden Wellness is painful. Regardless of the reason, discontinuing treatment is an integral part of the treatment process and deserves to be dealt with thoroughly. Due to the importance of the therapeutic relationship, we hope that the decision to discontinue treatment will be discussed in advance. Please rest assured in knowing we will initiate a discussion regarding discontinuing treatment if/when we believe your best interests would be best served by reducing the frequency of your sessions and/or discontinuing treatment. WHAT ARE MY RESPONSIBILITIES? Patients are expected to pay in full at the time of their appointment unless alternative arrangements have been made in advance. Any special financial arrangements regarding payment must be in writing, dated, on file, and signed by Raden Wellness and the patient/responsible party. Appointments may be billed according to time and/or service(s) provided. Telephone calls may be billed based upon a pro-ratted fee if deemed necessary. The fee for all services varies and is subject to change. Charges for time and/or services include printed materials, reports, letters, consultations, travel time for "out of office" services, and telephone calls. Patients are billed for any and all time spent with patients or on the patient's behalf. In the event a patient's financial situation changes during the course of treatment and they are unable to afford the services of a private practitioner, please discuss the matter with our office and we can explore available options. BILLING STATEMENTS Payment at the time of service is required for all appointments and/or orders and a statement can be provided for insurance and/or your own personal records upon request. However, statements for balances remaining and those that must be submitted directly to the insurance carrier are sent out on a monthly basis. In the event an additional copy of a statement is needed or if you need additional assistance with regards to receiving approval from your insurance carrier, please contact our office and we will attempt to assist. However, please be aware that we do not typically contact insurance carriers on the behalf of a patient. OVERDUE AMOUNTS Thirty (30) days after the original billing date a statement will be mailed to you and may include a $5.00 re-bill fee. Should an additional thirty (30) days pass, a final notice will be sent to the patient with any additional accrued charges. In the event an additional thirty (30) days pass without payment and no alternative arrangements have been made, the account may be sent to collections and the patient will be responsible for any legal and collection agency fees. PAYMENT Payment is due at the time of service. TAX RECORDS Depending upon the patient's financial circumstances and total medical costs for any given year, treatment may be a deductible expense. Raden Wellness recommends that patients keep a second copy of their statements, receipts, and/or invoices for their own tax records to assist in computing the feasibility of an income tax deduction at the end of the year. ETHICS AND PROFESSIONAL STATEMENTS As practitioners, we strive to uphold the most responsible, ethical, and professional standards possible. Should you have any questions or concerns regarding your course of contact with Raden Wellness, please discuss these issues with us directly. With your acknowledgment below, you are agreeing that in the event you experience any dissatisfaction or concerns regarding your treatment, or should you wish to contract your treatment with another practitioner for services, that you will make every effort to indicate that you are making a change and the reason you wish for the change to occur. In the event you are disatisfied with your services at Raden Wellness and need assistance finding additional/alternative assistance, we will do our best to assist you in locating a more suitable referral or treatment option. QUESTIONS Raden Wellness strives to provide patients with the ability to feel comfortable asking questions. We encourage patients to be educated regarding the care they are receiving. Should you have any questions regarding the nature of your treatment, goals, procedures, billing information, etc. please do not hesitate to contact us. A FINAL WORD The therapeutic relationship is a very personal and individualized partnership. We value patient feedback and encourage patients to share both positive feedback as well as recommendations for improvement. BEFORE SIGNING BELOW, PLEASE ASK ANY QUESTIONS YOU MAY HAVE REGARDING TREATMENTS AND/OR OFFICE POLICIES. YOUR ACKNOWLEDGMENT BELOW INDICATES THAT YOU HAVE READ OUR OFFICE POLICIES AND AGREE TO INITIATE TREATMENT UNDER THESE CONDITIONS. ADDITIONALLY, IT INDICATES YOUR UNDERSTANDING THAT WE MAY TERMINATE YOUR TREATMENT IN THE EVENT YOU DO NOT COMPLY WITH THE POLICIES OR WE FEEL YOU ARE NOT BENEFITTING FROM TREATMENT.
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Step 6.
Patient Information
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PRIVACY PRACTICES This notice describes how medical information regarding patients may be used an/or disclosed and how patients may access the information. Patients are encouraged to review this information carefully. Raden Wellness is committed to maintaining patient confidentiality. Healthcare information will only be released in accordance with federal and state laws and within the ethics of the counseling profession. USES AND DISCLOSURES OF PATIENT HEALTHCARE INFORMATION FOR THE PURPOSE OF PROVIDING SERVICES Providing treatment, collecting payment, and conducting healthcare operations are necessary activities for quality healthcare. State and federal laws allow us to use and disclose patient healthcare information for these purposes. TREATMENT Raden Wellness may need to use or disclose patient health information to provide, manage, and/or coordinate patient care and/or related services. Coordination of care may include consultations and potential referral sources. PAYMENT Information may be necessary for billing and collection purposes. Raden Wellness will bill the individual financially responsible for the patient's care and/or related services. HEALTHCARE OPERATIONS Raden Wellness may need to use patient information to review treatment procedures and business activity. Information may be used for certification, compliance, and/or licensing activities. OTHER USES OR DISCLOSURE OF PATIENT INFORMATION WHICH DOES NOT REQUIRE PATIENT CONSENT There are some instances in which Raden Wellness may be required to use and disclose information without patient consent. For example (but not limited to): information reported by patient and/or patient's child regarding physical or sexual abuse - by state law we are obligated to report such instances to the Department of Children and Family Services; in the evvent a patient states they are in danger of harming themselves or others; information reminding patients of appointments, rescheduling appointments, or alternatives to treatment; information shared with law enforcement in the event a crime is committed on business premises and/or against our staff or as required by law as a subpoena or court order. Patient Rights RIGHT TO REQUEST HOW WE MAY CONTACT YOU It is within our customary practice to communicate with patients using the home address and daytime phone number indicated as "Primary" within the patient's chart. Raden Wellness may contact patients using this information and may leave voicemail messages as well. Please note, portal messages sent via the Patient Portal or within our secure app is the most secure method of messaging with our office. In the event you would like to request specific communication methods, please contact our office. Any requests or refusal to utilize the patient portal will not be agreed to except in extenuating circumstances and at the determination of Raden Wellness staff. RIGHT TO RELEASE PATIENT MEDICAL RECORDS Patients may consent in writing to the release of their PHI to others. Patients have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we have acted in reliance on such authorization. RIGHT TO INSPECT AND COPY PATIENT MEDICAL AND BILLING RECORDS Patients have the right to inspect and obtain a copy of their information contained in our medical records. To request access to billing and/or health information, please contact our office, although the majority of information is available via the patient portal. In rare circumstances, Raden Wellness may deny a patient request to inspect and/or copy records. Any requests for copies of any information may be charged a reasonable fee for the costs of copying, mailing, and/or supplies. RIGHT TO ADD INFORMATION OR AMEND PATIENT MEDICAL RECORDS In the event a patient feels that information contained in their medical records is incorrect and/or incomplete, the patient may request that Raden Wellness add the information or amend the record. Alternatively, many corrections and/or additions may be completed by patients via the patient portal. A request to amend a medical record will be addressed within 60 days, or, in some cases, 90 days. Under certain circumstances a request to add or amend information may be denied. The patient request and the response will be added to the patient's medical record. To request an amendment that cannot be completed via the patient portal, please contact our office. The request must be submitted in writing and include an explanation regarding the reason for the request. RIGHT TO ACCOUNTING AND DISCLOSURE Patients have the right to request an accounting of disclosures, if any, which is a list of certain disclosures such as child or elder abuse, disclosures related to suicidal or homicidal threats, and/or disclosure to the United States Department of Health and Human Services to evaluate compliance. RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF PATIENT HEALTH INFORMATION Patients have the right to request restrictions on certain uses and disclosures of health information. These requests must be submitted to Raden Wellness directly and in writing, however, Raden Wellness is not required to agree to such a request. RIGHT TO COMPLAIN In the event a patient feels their privacy rights have been violated, please contact our office directly to discuss your concerns. In the event a patient is not satisfied with the outcome, patients may submit a written complaint to the United States Department of Health and Human Services. A patient will not be retaliated against for filing such a complaint. RIGHT TO RECEIVE CHANGES IN POLICY Patients have the right to receive any future policy changes secondary to changes in state and federal laws. This may be obtained from your practitioner and/or office staff.
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