New Patient Forms
Insurance Plans We Accept
Privacy Policy
Financial Policy

New Patient Forms

Please complete the new patient forms once you have scheduled an appointment with our office.  You will need Adobe Acrobat Reader to open this file. If you currently have this program, please click here to download the forms. To download this program for free, click here. For faster check in on the day of your appointment, you can now fax these forms in advance to 928.773.2281.  Please ensure that you selected which physician you are seeing at the top of the first page

Privacy Policy
Effective Date: April 14, 2003

This notice describes how personal health information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

We respect patient confidentiality and only release personal health information about you in accordance with the state and federal law.  This notice describes our policies related to the use of the records of your care generated by Flagstaff Bone and Joint (FBJ).

Privacy Contact:  If you have any questions about this policy or your rights contact the Privacy Coordinator at 928-214-2869.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

In order to effectively provide you care, there are times when we will need to share your personal health information with others beyond FBJ.  This includes for:

Treatment:  With your permission we may use or disclose personal health information about you to provide, coordinate, or manage you care or any related services,  including sharing information with others outside FBJ that we are consulting with or referring you to.

Payment:  Information will be used to obtain payment for the treatment and services provided.  This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes.

Healthcare Operations:  We may use information about you to coordinate our business activities.  This may include setting up your appointments, reviewing your care, and training of staff.

Information Disclosed Without Your Consent.  Under state and federal law, information about you may be disclosed without your consent in the following circumstances:

Emergencies:  Sufficient information may be shared to address the immediate emergency you are facing. 

Follow Up Appointments/Care:  We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required by Law:  This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect, including child abuse, elder abuse or institutional abuse.

Coroners, Funeral Directors:  We may disclose personal health information to a coroner or personal health examiner and funeral directors for the purposes of carrying out their duties.

Governmental Requirements:  We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure.  There also might be a need to share information with the Food and Drug Administration related to adverse events or product defects.  We are also required to share information, if requested, with the Department of Health and Human Services to determine our compliance with federal laws related to health care.

Criminal Activity or Danger to Others:  If a crime is committed on our premises or against our personnel we may share information with law enforcement officials to apprehend the criminal.  We also have the right to involve law enforcement and to warn any potential victims when we believe an immediate danger may exist to someone, or if we believe you present a danger to yourself.

PATIENT REQUESTS

You have the following rights under state and federal law:

Copy of record:  You may request to inspect the personal health record FBJ has generated about you.  We may charge you a reasonable fee for copying and mailing your record.

Release of Records:  You may consent in writing to release your records to others, for any purpose you choose.  This could include your attorney, employer, or others who you wish to have knowledge of your care.  You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization.

Restriction of Record: You may ask us not to use or disclose part of the personal health information.  This request must be in writing.  FBJ is not required to agree to your request if we believe it is in your best interest to permit use and disclosure of the information.  The request should be given to the Practice Manager who will consult with the staff involved in your care to determine if the request can be granted.

Contacting You:  You may request that we send information to another address or by alternative means.  We will honor such a request as long as it is reasonable and we are assured it is correct.  We have a right to verify that the payment information you are providing is correct.  Due to agency policy, we are not able to provide information by e-mail.

Amending Record:  If you believe that something in your record is incorrect or incomplete, you may request we amend it.  To do this, contact the Practice Manger and ask for the Request to Amend Health Information Form.  In certain cases, we may deny your request.  If we deny your request for an amendment, you have a right to file a statement stating that you disagree with us.  We will then file our response and your statement and our response to it will be added to your record.

Accounting for Disclosures:  You may request a listing of any disclosures we have made related to your personal health information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that you gave us specific consent to release.   It also excludes information we were required to release.  To receive information regarding disclosure made for a specific time period, no longer than six years, and after April 14, 2003, please submit your request in writing to our Privacy Coordinator.  We will notify you of the cost involved in preparing this list.

Questions or Complaints:  If you have any questions or complaints you may contact our Privacy Coordinator in writing at our office for further information. 

Changes in Policy:  FBJ reserves the right to change its Privacy Policy based on the needs of FBJ and changes in state and federal law.

Notice of Privacy Policy Revision Number 1
Effective Date:  April 14, 2003
Vicky Wuest, Privacy Coordinator
928-214-2869

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Financial Policy

Thank you for choosing Flagstaff Bone and Joint as your orthopaedic specialist.  Please carefully read this document and sign below.  This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients.  It is important that we work together to assure that payment for services is as simple and straightforward as possible.  Our billing department will be glad to discuss these policies with you.

Orthopaedic surgery is a specialty practice and your insurance plan may require that you obtain a referral from your primary care provider before being seen.  As the insured member, this is your responsibility.  We recommend that you contact your health insurance plan to determine if we participate with your plan, whether you need a referral before scheduling an appointment and to review what your insurance policy covers for orthopaedic services such as radiology, durable medical equipment, physical therapy, surgery and injectible medications.   

Flagstaff Bone and Joint participates with a variety of insurance plans.  We can answer general questions about which insurance plans we participate with.  Ultimately, however, it is your responsibility to determine whether or not we are a participating provider for your insurance plan.  It is also your responsibility to know your provisions for copays, deductibles and coinsurance.

We will bill your insurance plan regardless of our network participation. Once our claims are processed and we receive an explanation of benefits from your insurance plan we will follow their fee schedule if we are contracted with their plan.  If we are not contracted with your insurance plan we will follow the Flagstaff Bone and Joint fee schedule and bill you accordingly.

Your insurance plan may require you to supply certain information directly to them after our claim has been submitted.  It is your responsibility to comply with their request and submit the requested information back to them in a timely fashion.  If we receive notice from your insurance plan that they will not continue processing our claims until the information they requested from you is submitted, the balance will automatically become your responsibility until the claim is paid.  Your account will then be subject to our overdue invoice process outlined in the following paragraph.

If there is a remaining balance due after your insurance plan processes and/or pays, you have 30 days to make payment on our invoice.  Payment arrangements can be made for special circumstances by contacting our billing department immediately after receiving your first invoice.  It is your responsibility to make contact with our billing department to make special arrangements.  If your account becomes 30 days past due, you will receive a letter reminding you that you must satisfy this debt and pay the account within 10 days.  Please be aware that if your balance remains unpaid we will then refer your account to either Tevis Reich, Attorney at Law, or the Arizona Credit Bureau.  This will be an automatic assignment unless prior arrangements have been approved.  Should a collection action become necessary, there will be collection fees and court costs added to your account.

If you do not have insurance, please see our billing department to arrange a cash payment at time of service. For your convenience, we accept cash, check, Master Card, Discover and Visa. 

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

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