The Policy of Diabetes Plus Clinic PLLC dba Endocrine & Diabetes Plus Clinic of Houston
As a courtesy to our patients, we gladly file the necessary forms with your insurance to ensure you receive the full benefits of your medical coverage. We ask that you read your insurance policy to fully understand any benefit limitations. It's your responsibility to obtain necessary insurance referrals or authorizations. If you're concerned about coverage for our services, kindly contact your insurance company before your visit.Your responsibilities such as copay, coinsurance, or deductible will be estimated and collected during your visit unless your insurance indicates otherwise. If your insurance denies coverage or payment isn't received within 60 days of filing your claim, the amount will become due according to our self-pay fee schedule, which we update periodically. Remaining copay, coinsurance, or deductible payments are due once we hear from your insurance. Any overcharge based on the fee schedule after insurance processing will be credited to your account or refunded upon your request. However, service charges are non-refundable. Please note that your coverage is a contract between you and your insurance company. While we make good faith efforts to assist you in obtaining benefits, we can't compel your insurance to cover the services we provide. The Texas Department of Insurance (tdi.texas.gov, 1-800-252-3439) can assist with issues involving regulated health plans (if your insurance card has "TDI" or "DOI" on it).
Assignment and Release:
I authorize direct payment to Endocrine & Diabetes Plus Clinic of Houston by my insurance company. I accept financial responsibility for services not covered by my insurance. For Medicare Supplement policies, I request payment of benefits to be made on my behalf to Endocrine & Diabetes Plus Clinic of Houston for services provided by its providers. I also authorize the release of medical care information to my insurance company, including Medicare supplement plan insurers. My signature acknowledges that I've read, understood, and accepted this information.
Recognizing diverse financial situations, we offer various payment options. We accept major credit cards and checks (returned checks incur a $35 fee; inappropriate credit card disputes also result in a $35 administrative fee). For returned checks, you have 7 days to arrange alternative payment.
We reserve appointments for you and appreciate choosing Endocrine & Diabetes Plus Clinic of Houston. We'll remind you of appointments via calls/texts/emails. If contact efforts fail due to mailbox issues or busy lines, we might not reach you. An appointment is a reserved treatment time. Kindly extend the courtesy of canceling or rescheduling appointments in advance. Regular appointment cancellations without one business day's notice are subject to a $25 fee. Due to increasing last-minute cancellations, a $25 deposit is now required to confirm appointments, serving as a no-show fee. Three no-shows result in dismissal from the clinic.
I understand that unpaid accounts become delinquent after 30 days and are subject to a 1.5% monthly finance charge (18% APR) or $35, whichever is greater. Further delinquency may involve assigning the balance and fees to a collection agency.
Credit Card on File Policy:
We require all patients to provide a credit card on file, with only the last four digits visible for security. Cards can pay copay, coinsurance, deductibles, or balances. We'll charge the card for amounts less than $200 without notification. Declined payments incur a $35 fee. If unreturned reminder calls persist for a week, the account becomes delinquent after 30 days, invoking late fees.
We use calls/emails/voice/texts for non-sensitive, non-urgent matters like scheduling, reminders, balances, follow-up, surveys, medical items, and health promotions. We aim to enhance communication efficiency. Standard rates may apply. Protected health information (PHI) might be shared with third parties following HIPAA for benefit administration. Parties contractually commit to PHI confidentiality. Communications might be added to your medical record. Though we strive for security, these methods aren't foolproof. To opt out of texts, text “UNSUBSCRIBE” to 832-968-7003.
I authorize Endocrine & Diabetes Plus Clinic of Houston to use calls/emails/voice/texts for communication. I'll maintain up-to-date contact details.
Notice of Privacy Practices Written Agreement:
I've read and acknowledged Endocrine & Diabetes Plus Clinic of Houston’s Notice of Privacy Practices (https://www.endocrine.plus/npp). I know I can request a copy.
Consent for Treatment: I voluntarily consent to medical care and treatment by Endocrine & Diabetes Plus Clinic of Houston's providers, staff, and contractors. This includes necessary diagnostic and therapeutic treatments. Medicine isn't exact; I acknowledge no outcome guarantees.
Consent for obtaining medical and prescription history: I voluntarily consent to provide Endocrine & Diabetes Plus Clinic of Houston access to my medical and prescription history for treatment. This consent remains valid unless I revoke it in writing.
This section outlines the terms and conditions of using telehealth/telemedicine services, including the sharing of personal health information, the potential risks and benefits, and the patient's right to consent or withdraw from such services.
Telehealth/Telemedicine: Telehealth/telemedicine involves electronic communication to share medical information with healthcare providers, including primary care practitioners, specialists, nurses, and clinical care team members, to improve patient care. Family members, caregivers, legal representatives, or guardians may also participate in telehealth/telemedicine services. Patients will receive information about tests, treatments, and procedures, including their benefits, risks, complications, and alternatives, during telehealth/telemedicine visits. Telehealth/telemedicine services are provided to patients within the state of Texas. Patients are responsible for ensuring they use a safe and secure device with sufficient bandwidth for telehealth/telemedicine consultations. The same financial and other policies are consistently applied to both in-person and telehealth/telemedicine visits.
Types of Information: Telehealth/Telemedicine may involve the transmission of various types of health information, including progress reports, physiological data, videos, pictures, text messages, audio, and other digital forms of data.
Privacy and Confidentiality: Laws protecting the privacy and confidentiality of health information apply to telehealth/telemedicine. Information will only be shared with consent or for treatment, education, billing, and healthcare operations.
Security Measures and Technical Issues: Electronic systems used for telehealth/telemedicine will incorporate security protocols to protect patient identification and data confidentiality. Other individuals may have access for technical support and will adhere to privacy and security policies. There's a risk of technical issues during telehealth sessions, and the patient releases healthcare providers from liability for data breach or loss due to technical failures.
Limited Access to Data: Patients understand that health information provided during telehealth visits may be the primary source of data for evaluation and treatment, as opposed to in-person visits or full medical records.
Right to Withdraw Consent: Patients have the right to withdraw consent for telehealth/telemedicine services at any time without affecting future services or benefits.
TERMINATING THE PHYSICIAN-PATIENT RELATIONSHIP
The policy of Endocrine & Diabetes Plus Clinic of Houston is to cultivate a therapeutic and trusting relationship with all patients. If such a relationship hasn't been established or if the patient-provider interaction becomes ineffective, the attending provider retains the right to terminate the relationship. This includes all family members of the patient and extends to interactions with any other provider within our practice. Termination will align with state, federal, and professional guidelines such as those set by the American Medical Association, in addition to this policy. The goal of relationship termination is to ensure seamless continuity of care for the patient.
When patients consistently cancel appointments, procedures, or scheduled care without valid cause or adequate notice, it adversely affects the quality and continuity of care. This disrupts office schedules and hinders the appointments of other patients. In an effort to mitigate such instances, a "No-Show fee of $25.00" may be imposed, and in cases where deemed appropriate, this may result in the termination of the physician-patient relationship.
Causes for Termination: The physician or designated representative may identify patients with whom the physician-patient relationship has deteriorated or is no longer therapeutic. Circumstances leading to termination can include, but are not limited to, the following:
• Repeated failure to adhere to therapies or treatments vital for the patient's safety, as deemed medically necessary by the physician or attending healthcare provider.
• Failure to fulfill financial obligations to Endocrine & Diabetes Plus Clinic of Houston for a period exceeding 3 months.
• Consistent or recurring failure to honor appointments without valid justification or providing notice to cancel appointments three or more times.
• Displaying threatening, violent, abusive, or patterns of repetitive rude or offensive behavior directed at a provider, staff, other patients, or visitors.
• Attempting to misuse the relationship to unlawfully or inappropriately acquire controlled substances for non-therapeutic purposes, abusing controlled substances, or declining treatment for controlled substance abuse or addiction. This includes seeking multiple prescriptions from different physicians or diverting controlled substances.
• The patient chooses to terminate or expresses a desire to end the relationship.
Endocrine & Diabetes Plus Clinic of Houston aspires to provide the most appropriate care for all patient healthcare needs. Our aim is to maintain a provider-patient relationship characterized by trust and respect.
PRESCRIPTION REFILL, PREAUTHORIZATION, AND ASSISTANCE PROGRAM
Prescription refills are exclusively available to patients under the continued care of Endocrine & Diabetes Plus Clinic providers. Continued care is determined by past and future appointments. Refills will not be provided if it's observed that continued care is not maintained (no appointment for 3-6 months or longer). For patients requiring close monitoring, prescriptions will solely be provided during appointments.
Endocrine & Diabetes Plus Clinic of Houston may assist in completing preauthorizations as a courtesy when medically necessary and without disrupting our standard operations. However, we lack influence over your insurance's policies, formulary, and decisions. Similarly, we do not provide appeals or peer-to-peer interactions with your insurance for the same reasons.
Endocrine & Diabetes Plus Clinic of Houston may also assist in completing medication assistance program paperwork as a courtesy when medically necessary and without causing disruptions beyond our usual workflow.
I, the undersigned, am either the patient 18 years of age or older or the duly authorized representative of the patient. I acknowledge having read and fully comprehended this consent form with all my questions answered, and hereby consent to the outlined conditions and instructions .