Privacy Practices & Other Notices

Your Information. Your Rights. Our Responsibilities.

At CloseKnit, we are committed to keeping your health record confidential, secure and private. This notice represents our commitment to the Privacy Rule, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) along with a brief overview of our Notice of Privacy. Federal and state laws require Comprehensive Primary Care to protect your health information and to inform you on how we handle that information. As such, this notice describes how medical information about you may be used and disclosed.

Our Uses and Disclosures

Our Uses and Disclosures Overall

Our Uses and Disclosures With Your Authorization

You Have the Right To

Additional Information

The Notice of Privacy Practices is available on our website at http://www.closeknit.com/patient-forms in English and Spanish. You may also visit our offices for a copy of the Notice. Our practice is compliant with the Americans with Disabilities Act of 1990 and will make this Notice available to patients with disabilities upon request in alternative formats.

Actions You May Take

If you have any questions regarding this notice or our health information privacy policies; or if you believe that we may have violated your privacy rights; or disagree with a decision that we made about access to your PHI; you may contact us at the following address, email address or phone number.

CloseKnit CC: Privacy Officer
15245 SHADY GROVE RD, SUITE 340, ROCKVILLE, MD 20850-7201
EMAIL: privacy@closeknit.com
PHONE: (410) 605-2555

CloseKnit is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our organization and outlines your rights regarding your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices or have access to the documents on our website.

I acknowledge that I have received a copy of the Notice of Privacy Practices of CloseKnit.

Consent to Access Prescription History

I authorize CloseKnit and its providers to view my external prescription history via Athena EHR system. I understand that this includes but is not limited to prescription history from other unaffiliated medical providers, insurance companies, and or pharmacy benefit managers may be viewable by providers and staff at CloseKnit. This also may include prescriptions dating back several years.

Consent to Treat

I, legal adult patient or the legal guardian, consent for myself or the patient to receive medical care, testing and treatment by any company Provider. This may include medical examinations, treatments, prescribing and giving medications, injections, immunizations, screenings and questionnaires, diagnostic testing, laboratory procedures, in-office procedures, arrangement for healthcare services, emergency services by the provider, other licensed staff members or staff under the supervision of licensed provider for this visit, future visits, and telehealth visits. I Understand that rendering providers may include physicians, nurse practitioners, physician assistants, and other clinicians as well as students, trainees, and clinicians both employed and not directly employed by the Practice.

I understand the right to consent or refuse to consent to any medically necessary treatment or procedure, except as otherwise required by law. I understand that I have the right to discuss all medical treatments with the providers. I understand that no guarantees have been made regarding diagnosis, treatment or care that I may receive. I understand that this consent to treatment must be signed, in order for the me to be seen and will be considered valid until such time that the Patient revokes this consent in writing.

Assignment of Benefits

The insurance and billing information provided is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance not covered by my insurance. I also authorize CloseKnit or insurance company to release any information required to process my claim.

Release of Healthcare Information

Patient authorizes the Practice to share the Patient's protected health information for treatment and payment purposes.

Practice Policies

NON-DISCRIMINATION: Copy available upon request through front desk, on our website at https://www.closeknit.com/statement-of-non-discrimination, or by request privacy@closeknit.com.

CONSENT TO ELECTRONIC COMMUNICATION: Patient authorizes the Practice to use Patient's information to send reminders regarding upcoming appointments, to obtain feedback on the practice experience and to provide general health information via e-mail and/or text messaging.

PATIENT FORMS: There may be a $25.00 fee for all forms that are dropped off during unscheduled appointments. In order to be exempt from this charge you will need to schedule an appointment with a provider. If your forms are not available at the time of service, you have 7 days to drop them off to avoid the fee. After 7 days the $25.00 form fee will apply.

MEDICAL CHAPERONE: Copy available upon request through front desk, website on www.closeknit.com/patient-forms, or by request privacy@closeknit.com.

APPOINTMENTS: Once an appointment has been made, please respect the time that has been reserved in our office schedule for you. There will be a $50.00 charge for missed appointments and appointments not cancelled within 24 hours. We make every attempt to give our patient a courtesy call reminding you of your appointment time, but it is your responsibility to make sure you have this information, so you do not miss your appointment.

To ensure timely care for all patients and maintain the integrity of our schedule, we ask that all patients arrive promptly for their appointments. Patients who arrive late may be asked to reschedule their appointment, at the discretion of the provider and based on the day's schedule and patient volume. The practice reserves the right to reschedule late arrivals to avoid delays for other patients and to ensure adequate time for clinical care. Repeated late arrivals may result in additional administrative action, including discharge from the practice. We appreciate your understanding and cooperation in respecting the time of all patients and staff.

BILLING: Patients must pay co-pay before each visit. Any returned checks will be subject to a $30.00 charge. After three bills, the account will go to collections. We are happy to make payment arrangements with you.

Our goal is to provide you with the best medical care possible. Annual physical exams give us a chance to address your overall physical and emotional health. The preventative care we provide during a physical also includes an assessment of dietary and exercise habits, review of vaccinations, discussion of screening tests, lifestyle behaviors, etc. We often look in on chronic stable problems such as high blood pressure, arthritis, and/or other ongoing controlled medical conditions.

Regular office visits differ from the preventative and wellness care provided at a physical because they focus on other new ongoing or poorly controlled medical concerns. These types of problems need to be addressed in an appointment separate from a preventative or physical exam. If, however, we adequately cover required preventative and wellness care during the physical, sometimes we will have time to discuss new problems identified by you or the physician.

We would like to correct a misperception that is occurring regarding "double charges". Please note that the insurance companies do allow providers to address additional complaints beyond a physical examination. If new problems are found or poorly controlled problems are addressed, an additional office evaluation code will be generated in addition to a preventative physical examination code. Essentially, part of the visit is preventative, but part of the visit is not part of a wellness exam. Therefore, this generates another charge to the insurance company which in turn may require you to pay your copayment, coinsurance or deductible charge.

Refund Policy: It is the policy of CloseKnit that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay for their copay, deductible and or coinsurance payment at the beginning of each visit. At the conclusion of your visit, you may be billed for any outstanding balance. If there is a valid credit applied to your account and your account has been reviewed and approved a refund will be provided by mail in the form of a check.

If you have any further questions regarding your payment/refund for any date of service, please contact the billing department.

CONSENT TO TELEHEALTH: I agree to care and treatment involving the use of electronic communications by telephone and/or by video or other transmitted information.

REFERRALS: Your insurance company, not this office, establishes referral policies. Please note that referrals require up to 72 hours to process. When requesting a referral, please include your name, date of birth, insurance company name, insurance ID number, specialist name, specialty, and reason for visit. We will notify you when your referral is ready for pick up or we can send it to you via USPS Mail. We will automatically send it via facsimile or electronically to your specialist. Same day referrals are limited to medical emergencies. WE DO NOT BACK DATE REFERRALS, according to your insurance and our office policies. If you are unsure whether your insurance plan requires referrals, please ask the front desk or you may call your insurance company.

PRESCRIPTION REFILLS: Please be aware that it is your responsibility to have an adequate supply of your routinely prescribed medication on hand to last you until your next office visit. For example, blood pressure, cholesterol and diabetes medication. You will be instructed as to when you are required to schedule your next follow-up appointment. If you are running out of medication, please inform our office within an adequate amount of time. We will not prescribe pain medication or antibiotics without having an appointment with one of our providers. You are required to have a follow-up appointment every 3 months for refills on your controlled substance medications. Some examples would be medication for anxiety, sleep aid, ADHD or depression.

PRIOR AUTHORIZATION: Your insurance company, not this office, sets medication formularies. We make every effort to adhere to these formularies, which frequently change. If the medication prescribed is not covered by your insurance, our preference is to change to an alternative medication on your formulary-preferred list. As a second option, we will complete a prior authorization on your behalf. Please be aware that this process may take 3 to 5 business days to complete. This may vary based upon your insurance plan and or the medication prescribed.

LAB RESULTS: Effective January 4, 2010, we will no longer mail results of any kind. We now have a patient portal either through our website or through the CloseKnit portal for patients to review their lab results. This will allow patients to access a portion of their medical record securely online. For abnormal results, we will make every effort to promptly contact you. Please be sure the office has your correct telephone number.

If you are contacted due to an abnormal result, you may be asked to schedule a follow up appointment with your provider. We understand that some patients may not have access to the web or may still want an actual copy of their results. In those instances, be sure to notify the office so we can leave a copy of your results at the front desk for pick up.

If you do not hear from us within 10 days after completing the test, be sure to contact the office to obtain the results.

MEDICAL RECORDS: To obtain medical records from our office, please send a signed HIPAA compliant medical record release form. Please be sure to complete the form in its entirety. A fee may apply to this request. Payment is required prior to releasing the medical records. If you have any additional questions, please contact the medical record department.

MEDICAL TEACHING & TRAINING: Patient understands and gives consent to the providers, clinicians, and other health professionals may be involved in training during the Patient's treatment.

MEDICAL IMAGES: Patient authorizes photos may be made of the Patient for the purpose of care or medical teaching.

ADVANCED MEDICAL DIRECTIVES: Advanced Medical Directives are available in the office, please ask a staff member or your provider if you would like to obtain one. Once completed, please provide us with a copy so we can incorporate it into your medical record.

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