Privacy and Office Policies

PRIVACY POLICY

MOSAIC MIND PSYCHIATRY

PATIENTS’ RIGHTS AND RESPONSIBILITIES 

 

Acknowledgment of Receipt of HIPAA Notice of Privacy Practices

This document contains important information about your rights under federal law, specifically the Health Insurance Portability and Accountability Act (HIPAA). Under HIPAA, patients must be provided with a Notice of Privacy Practices that explains how their PHI may be used and disclosed.

Use and Disclosure of Protected Health Information

Your Protected Health Information (PHI) may be used and disclosed for purposes related to treatment, payment, and healthcare operations, as permitted under the Health Insurance Portability and Accountability Act (HIPAA).

  1. Treatment: Your health information may be used within the practice as part of your ongoing treatment. If it becomes necessary to share information with another healthcare provider involved in your care outside of this practice, you will typically be asked to sign an Authorization for Release of Information before any information is disclosed, as required by law.
  2. Payment: Your health information may be used or disclosed to obtain payment for services provided to you, including submitting information to your insurance provider or other responsible parties, as outlined in your Consent to Treatment or Financial Policy.
  3. Healthcare Operations: Your health information may also be used as part of the practice’s internal operations. This may include activities such as quality assurance reviews, staff training, auditing, or administrative functions necessary to maintain and improve the quality of care provided. From time to time, we may also use your contact information to inform you about services, educational opportunities, or information that may be relevant to your care.

Limits of Confidentiality and Permitted Disclosures

Federal law protects the privacy of communications between a patient and a healthcare provider. In most situations, Mosaic Mind Psychiatry may only release information about your treatment to others if you provide written authorization that meets the legal requirements established by the Health Insurance Portability and Accountability Act (HIPAA). However, there are certain situations permitted or required by law to disclose information without your written authorization. If such a situation arises,  the disclosure will be limited to the minimum amount of information necessary.

Examples of situations where your information may be disclosed without authorization include:

  1. Legal: Law Enforcement Requests, Court Orders or Subpoena’s
  2. Health Oversight Activities: Government agencies responsible for healthcare oversight may request information for audits, inspections, investigations, or other authorized activities. 
  3. Professional Complaints or Legal Claims: If a patient files a complaint or legal claim, it may be necessary to disclose relevant information as necessary to respond to the complaint.
  4. Workers’ Compensation Claims: If a patient were to file a workers’ compensation claim, Mosaic Mind Psychiatry may be required to submit treatment reports related to claim to appropriate parties such as employer, insurance carrier, or an authorized rehabilitation provider.
  5. Business Associates: Individuals or organizations that perform services for the practice such as billing or administrative support. These entities are required to sign agreements to protect the privacy and security of your information.
  6. Situations Requiring Disclosure to Prevent Harm
    1. Serious threats to health or safety
    2. Suspected Child Abuse or Neglect
    3. Abuse, Neglect, or Exploitation of a Vulnerable Adult
    4. Public Health reporting and disease prevention

A patient has the right to:

  • respectful care given by competent personnel which reflects consideration of personal value and belief systems and which optimizes comfort and dignity. 
  • know what facility policies, rules and regulations apply to conduct as a patient. 
  • good quality care and high professional standards that are continually maintained and reviewed. 
  • expect emergency procedures to be implemented without unnecessary delay. 
  • medical services without discrimination based upon race, color, religion, gender, sexual preference, handicap, national origin, or source of payment. 
  • make decisions involving health care, in collaboration with the practitioner. While Mosaic Mind Psychiatry recognizes the right of the patient to participate in care and treatment to the fullest extent possible, there are circumstances under which the patient may be unable to do so. In these situations (e.g. if the patient has been adjudicated incompetent in accordance with the law, or is found to be medically incapable of understanding the proposed treatment, or is unable to communicate wishes regarding treatment) the patient’s rights are to be exercised, to the extent permitted by law, by the designated representative or other legally designated person. 
  • upon request, be given the name of the supervising physician, and the names of all other physicians or practitioners directly participating in care
  • receive care in a safe setting, and be free from all forms of abuse and harassment. 
  • to have all information, including records pertaining to medical care treated as confidential except as otherwise provided by law or third party contractual arrangements.
  • have medical records read only by individuals directly involved in care, by individuals monitoring the quality of care, or by individuals authorized by law or regulation. 
  • be communicated with in a manner that is clear, concise and understandable. If the patient does not speak English, they should have access, where possible, to an interpreter. 
  • full information in layman’s terms, concerning diagnosis, treatment and prognosis, including information about alternative treatments and possible complications. 
  • accept medical care or to refuse any drugs, treatment, or procedure offered by the practice, to the extent permitted by the law; a provider shall inform the patient of the medical consequences of such refusal.
  • participate in the consideration of the ethical issues surrounding care, within the framework established by this organization to consider such issues. 
  • examine and receive a detailed explanation of the bill. 
  • full information and counseling on the availability of known financial resources for their health care. 
  • voice complaints regarding care, without recrimination; to have those complaints reviewed, and when possible, resolved. 
  • The patient cannot be denied the right of access to an individual or agency who is authorized to act on their behalf to assert or protect the rights set out in this section. 

 

 A patient should act in accord with practice policies, rules, and regulations and assume responsibility for the following: 

 

  • the practice expects that a patient, or their designated/legal representative, will provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, “advance directives”, and other matters relating to the health history or care in order for them to receive effective medical treatment.
  • reporting whether they clearly comprehend a contemplated course of action and what is expected of him/her. 
  • Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate.  Together, we will discuss whether or not releasing the information in question to that person or agency might be harmful to you.
  • cooperating with all practice personnel and ask questions if directions and/or procedures are not clearly understood. 
  • being considerate of other patients and practice personnel, to assist in the control of noise and visitors in the room, and to observe the smoking policy of this institution. A patient is also expected to be respectful of the property of other persons and the property of the Medical Center. 
  • Duly authorized members of a patient’s family or designated/legal representative are expected to be available to health care personnel for review of treatment in the event they are unable to properly communicate with health care givers. 
  • assuming the financial responsibility of paying for all services rendered either through third party payers (insurance company) or being personally responsible for payment for any services, which are not covered by insurance policies. 

 

COMPLAINTS

If the patient or a family member thinks that a complaint or grievance remains unresolved through the office processes, they have the right to contact the Division of Acute and Ambulatory Care, PA Department of Health. P.O. Box 90, Health and Welfare Building, Harrisburg, PA 1180-0090, (800) 254-5164.

FINANCIAL POLICY/GOOD FAITH ESTIMATE

Patient Financial Responsibility and Office Policies

 

Thank you for choosing MOSAIC MIND PSYCHIATRY for your care. The following policies are designed to ensure clear communication, efficient scheduling, and continuity of care for all patients. By receiving services from our practice, you acknowledge and agree to both office and financial policies outlined below.

Payment for Services

Payment is due at the time services are rendered unless other arrangements have been made in advance. We accept payment by credit card, debit card, electronic payment, or other approved methods. 

Patients are responsible for all fees associated with services provided, regardless of insurance coverage.

Insurance

If we participate with your insurance plan, we will submit claims on your behalf as a courtesy. However, verification of insurance benefits does not guarantee payment. Patients remain responsible for any charges not covered by their insurance plan, including but not limited to:

  • Copayments
  • Coinsurance
  • Deductibles
  • Non-covered services

Copayments and estimated patient responsibility are due at the time of the appointment.

If your insurance company denies or delays payment, the outstanding balance may become the patient’s responsibility.

Self-Pay Patients

Patients who do not use insurance are responsible for full payment at the time of service unless other arrangements have been made. Fees for services may vary depending on the type and length of the appointment. Current fee schedules are available upon request.

Outstanding Balances

Patients are responsible for maintaining a current account balance. If an account becomes significantly overdue, the practice may require payment before scheduling additional appointments.Unpaid balances may be referred to a collection agency if reasonable efforts to obtain payment have been unsuccessful.

Returned Payments

Returned checks or failed electronic payments may be subject to an additional processing fee.

Records, Forms, and Administrative Requests

Fees may apply for certain administrative services that may not be covered by insurance, including but not limited to:

  • Completion of forms
  • Medical record copies
  • Disability or legal documentation
  • Extended phone consultations
  • Requested Letters (Jury duty excuse, ESA, accommodations, etc)

Changes to Fees or Policy

Fees and financial policies may change periodically. Patients will be notified of significant changes when possible. It is patients responsibility to review policies prior to each appointment for any changes that have been made.

Good Faith Estimate Notice for Self-Pay or Uninsured Patients

Under the No Surprises Act, health care providers are required to provide patients who do not have insurance or who are not using insurance with an estimate of the expected charges for medical services. You have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.
  • You can also ask your health care provider for a Good Faith Estimate before scheduling a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or photo of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit
https://www.cms.gov/nosurprises or call 1-800-985-3059.

Missed Appointments and Late Cancellations
If you miss an appointment (“no-show”) or cancel without providing at least 24 hours’ notice, it will be your responsibility to contact the office to reschedule. Rescheduled appointments will be offered at the provider’s next available opening, which may be several months away.

Repeated missed appointments significantly disrupt patient care and scheduling. If you have two or more consecutive no-shows or cancellations without at least 24 hours’ notice, you may be removed from the provider’s schedule and may be subject to termination from the practice.

To remain an active patient of the practice, patients must complete at least one appointment per year. Patients who do not meet this requirement may be considered inactive and may need to re-establish care as a new patient.

Late Arrivals

Appointments are time-based and begin at the scheduled time. Patients who arrive late will be offered the remaining time in their appointment slot in order to avoid delaying other scheduled patients. For example, if you arrive 10 minutes late for a 30-minute appointment, the appointment may be limited to the remaining 20 minutes. Patients may choose to proceed with the shortened visit or reschedule the appointment, in which case a missed appointment or late cancellation fee may apply. The provider reserves the right to determine when there is insufficient time remaining to conduct an appropriate visit, in which case the appointment will need to be rescheduled.

Medication Refills
For non-controlled substance medications, patients are encouraged to request refills during their scheduled appointments whenever possible. When clinically appropriate, the provider may issue prescriptions for up to a 90-day supply.

Controlled substances will generally be prescribed in 30-day increments only, and patients must be seen for follow-up at least every three (3) months in order to continue receiving these medications.

Refill requests between appointments may be submitted as needed. Please allow at least three (3) business days’ notice for all prescription refill requests. Refill requests are processed during regular business hours, Monday through Friday, and we make every effort to complete requests within three business days.

Before contacting the office, please review your medications to ensure that you are requesting refills only for medications prescribed by our practice.

Termination Policy and Procedure

You have the right to terminate treatment at any time.

MOSAIC MIND PSYCHIATRY reserves the right to terminate treatment for the following reasons:

  • The provider determines that your clinical needs are beyond the scope or capability of services offered by the practice.
  • Failure to adhere to the treatment plan, including but not limited to misuse of prescribed medications, failure to notify the provider of significant changes in your condition, two or more consecutive no-shows or cancellations without at least 24 hours’ notice, or repeated cancellations that result in extended gaps in treatment.
  • Failure to pay outstanding charges on your account, including missed appointments or no-show fees.
  • Inappropriate or disruptive behavior, including but not limited to threats, harassment, derogatory language, or behavior that interferes with the safe and respectful operation of the practice.

If MOSAIC MIND PSYCHIATRY terminates your care, you will receive written notice outlining the reason for termination. The standard notice period is 90 days, during which time you may seek care from another provider. The 90-day notice period may be waived if termination is due to non-adherence with the treatment plan or inappropriate behavior, as these circumstances constitute a violation of practice policies.