We would like to take a moment to thank all of our patients. We strive to give you and your family the care you deserve. We would like to remind everyone of our clinic policies to ensure your needs are met
in an efficient and timely manner.
There may be a charge of $10.00-$25.00 if you bring paperwork to the physician for them to complete. This includes, but is not limited to, FMLA paperwork, insurance forms (other than the form required for us to file your claim) and disability forms. This will not be billed to your insurance company and must be paid when the forms are picked up.
Effective Date: June 2, 2016
Arkansas Central Primary Care, Pllc
1300 Braden St.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Call Us: (501) 843-4555
It is our financial policy to bill your insurance carrier as a courtesy to you, although you are responsible for the entire balance now. Once the carrier is billed, we will set aside that portion of the balance estimated to be paid by your insurance carrier for 30 days. We require that your estimated share be paid now. If your insurance carrier does not remit payment within 30 days, the balance will be due in full from you. It is not our policy to contact carriers to establish why they haven't paid or why they paid less than originally indicated.
Copays, deductibles and coinsurance amounts are due at the time the services are rendered. We gladly accept personal check, cash, VISA, MasterCard and American Express. Prior arrangements must be made if you are unable to make payment on the day of your appointment. There will be a charge of $15.00 for all returned checks.
If you have any questions about this notice, please contact the Privacy Officer at 501-985-5994.
This notice describes privacy practices of Arkansas Central Primary Care, Pllc dba Jacksonville Medical Care, Cabot Medical Care and Family First Pharmacy.
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in our office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or other medical personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We also may share medical information about you with other healthcare providers who are treating your medical conditions in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
We may use and disclose medical information about you so that the treatment and services you receive at our office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received at our office so your health plan will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Healthcare Operations.
We may use and disclose medical information about you for healthcare operations. These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many of our patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other physician offices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research project and established protocols to ensure the privacy of your health information. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. We may also disclose medical information about you to people preparing to conduct a research project, for example to help them look for patients with specific medical needs, so long as the medical information they review does not leave the clinic.
Communication With Family.
Healthcare professionals, using their best judgment, may disclose to a family member, a close personal friend or any other person you identify, health information needed for that person to be involved in your care or payment related to your care.
As Required By Law.
We will disclose medical information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety.
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Military and Veterans.
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks.
As required by law, we may disclose medical information about you to authorities charged with preventing or controlling disease or disability.
Health Oversight Activities.
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
We may release medical information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; about a death we believe may be the result of criminal conduct; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors.
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities.
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others.
We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Other uses and disclosures of medical information not covered by this notice, specifically those for marketing, the sale of PHI, and psychotherapy notes, will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time and we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Obtain a Copy.
You have the right to inspect and obtain either a paper or electronic copy of medical information that is used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and obtain a copy of medical information that may be used to make decisions about you, you must submit your request in writing, to Arkansas Central Primary Care, addressed to the Medical Records or the Privacy Officer. If you request a copy of the information, we may charge a fee of $0.25 per page.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed.
Another licensed healthcare professional chosen by our office will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend.
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Clinic.
To request an amendment, your request must be made in writing by completing the “Request to Amend Medical Record Form”. You may get a copy of the “Request to Amend Medical Record Form” in-person, mail or print it from our website.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Right to Receive Notice of a Breach.
You have the right to receive notice if there is a breach of your protected health information.
Right to an Accounting of Disclosures.
You have the right to request an "accounting of disclosures." This is a list of some of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to Arkansas Central Primary Care addressed to the Privacy Officer. Your request must state a time period which may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a twelve (12) month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a particular type of treatment you had.
We are not required to agree to your request.
However, we must agree to a request to restrict the disclosure of your protected health information to a health plan if you request the restriction in writing and in advance of any of the services being provided and if you have paid Clinic in full for the services, out-of-pocket, in advance.
Right to Request Confidential Communications.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, inquire at the reception desk.
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will contain the effective date. In addition, each time you register for treatment or healthcare services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Privacy Officer at Arkansas Central Primary Care-1300 Braden St. Jacksonville, AR 72076. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
We are required to and will request that you sign a separate form or notice acknowledging you have received a copy of this notice. The acknowledgement will be filed with your records. Refusal to sign does not prohibit Arkansas Central Primary Care, Pllc from using or disclosing your information in accordance with this Policy and it will be documented in your Medical Record that you refused to sign the acknowledgement.