INSURANCE POLICY

The physicians at Mt. Auburn Ob/Gyn participate with many insurance companies and managed care networks. Prior to your visit please contact your insurance carrier to confirm your benefits and verify our participation in your plan. Please remember that the insurance company will only provide an estimate of benefits and not a guarantee of payment. In order for us to bill your insurance company we ask that you present your insurance card to the receptionist at each visit.

BILLING POLICY

Co-Payments
All co-payments will be due and collected at the time of service.

Co-Insurance and Deductible Responsibilities
We will make every effort to verify your co-insurance and/or deductible amounts prior to your delivery, surgery, or procedure. Any out-of-pocket expenses are due prior to the services.

Payment Plans
Our billing department is available to work with you in setting up a payment plan for large balances. Please contact one of our Billing Specialists at the number listed below to discuss payment plan options. For you convenience, we accept Visa, MasterCard, Discover, and American Express.

No Insurance/Self-Pay Patients:
Payment in full is due at the time of service for office visits. Payment plans are available for delivery, surgery, or procedures and can be arranged by calling one of our Billing Specialists at the number listed below.

Past Due Accounts:
In the event that a balance becomes past due your account will be considered delinquent and subject to collection action. As a final step, past due accounts will be referred to an outside collection agency and become the responsibility of the agency.

Returned Checks: A fee of $25 for checks returned to us with insufficient funds will be charged to your account.

Disability and Other Forms:
Completing forms is both time consuming and costly. We will be happy to complete an initial form for you free of charge. Each additional form must be accompanied with a filing fee of $20 prior to completion. Please allow 7 to 10 days for completion of forms.

Billing Office Hours and Contact Numbers:
Mon-Thursday 8:00 AM- 5:00 PM
Friday 8:00 AM- 4:00 PM
Phone: 513-229-3903
Fax: 513-229-3905

Make An Appointment

For an annual appointment please contact our office three months prior to the time you wish to be seen. When you call, let us know of any issues that may indicate you need to be seen sooner.

If you are experiencing an emergency call the office immediately.

If you need to reschedule or cancel an appointment, please give us 24 hours notice. This courtesy allows us to offer that time to another patient. Failure to provide 24 hours notice may result in a service charge.

Our group practice enables us to handle any urgent case. We appreciate your patience should you encounter an unforeseen delay due to an emergency. We respect your time and make every effort to see you promptly.

To make your first visit easier, we have provided our new patient forms as well as our patient privacy form on our website. You may download these forms and bring them with you to your office visit, or you may fax them to the appropriate office. The office fax numbers listed to the left. If you are unable to open these forms, please download Adobe Reader from the link below.

Patient Forms

Calls for Physicians

If you have a problem that needs immediate attention please call the office. During regular business hours a staff member will take your call, consult with your physician and call you back as soon as possible.

One of our doctors is always available for emergency calls after regular office hours. To reach the on-call physician, call any of our offices. The answering service will contact the physician who will promptly return your call. Please limit after-hour calls to emergencies.

Prescription Refills

Please request prescription refills early in the day so that we have enough time to consult with your doctor and call the pharmacy. We refill prescriptions only during office hours. Please have your pharmacy telephone number available when you call.

Prescription requests after regular business hours may incur a $25.00 service charge.

Hospital Admissions and Surgery Scheduling

If your physician recommends hospitalization or surgery, our office staff will work with you on the necessary steps. Our physicians provide care for our patients at The Christ Hospital.

Test Results

All test results, including sonograms and Pap smears, are reviewed by our medical staff. If the results are abnormal we will contact you regarding treatment and follow up care. Be sure we have your current telephone numbers, email and address in your records.

Notice of Privacy Practices of MT. AUBURN OB/GYN.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

CONTACT PERSONS; If you have any questions about this notice, please contact: Mt. Auburn OB/Gyn 2123 Auburn Avenue, Suite 724 Cincinnati, OH 45219 (513)241-4774

This notice describes our organization?s practices as they relate to the use and disclosure of your medical information.

WHO WILL FOLLOW THIS NOTICE. ?

• Any health care professional authorized to enter information into your medical chart.?
• Any member of a volunteer group we allow to help you while you are our patient.
• All employees, staff and other professional personnel of our organization.
• The persons listed above may share your medical information with each other for the treatment, payment or health care operation purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION: 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 at our organization. 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 or maintained by us, whether made by our personnel or other health care providers. 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:

(1) make sure that medical information that identifies you is kept private;

(2) give you this notice of our legal duties and privacy practices with respect to medical information about you; and

(3) follow the terms of the notice that are currently in effect. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. 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.?

• For Treatment. 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, medical students, or other health care personnel who are involved in taking care of you at our organization. For example, a physician who is treating you for a certain gynecological condition may need to know if you are on any medications that may have an affect on decisions related to additional medications that may be prescribed to you in treating the condition. We also may disclose medical information about you to people outside our organization who may be involved in your medical care such as family members, clergy or others we use to provide services that are part of your care.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive from us 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 treatment information about any treatment you receive so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, authorization, or to determine whether your health plan will cover the treatment.
• For Health Care Operations. We may use and disclose medical information about you for our administrative operations. These uses and disclosures are necessary to run our organization 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 our organization should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other health care personnel for review and learning purposes. We may also combine the medical information we have with medical information from other organizations 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 health care and health care delivery without learning who the specific patients are. ?
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
• Treatment Alternatives. We may use and disclose medical information to recommend or tell you about possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
• Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition if you are hospitalized. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
• 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.

SPECIAL SITUATIONS

• 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.
• Workers? Compensation. 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. We may disclose medical information about you for public health activities.
• 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 health care 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.
• Law Enforcement. 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.
• 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 of the hospital 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.

YOU HAVE THE FOLLOWING RIGHTS REGARDING MEDICAL INFORMATION WE MAINTAIN ABOUT YOU:

• Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to one of the contact persons listed on page one of this notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. 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 health care professional chosen by the organization 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 our organization. To request an amendment, your request must be made in writing and submitted to one of the contact persons listed on page one of this notice. In addition, you must provide a reason that supports your request. 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:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for our organization;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an ?accounting of disclosures.? This is a list of the disclosures we make of medical information about you without your authorization or unrelated to your treatment, payment for your treatment, or our organization?s health care operations. To request this list or accounting of disclosures, you must submit your request in writing to one of the contact persons listed on page one of this notice. Your request must state a time period that may not be longer than six 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 or electronically). The first list you request within a 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 health care 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 surgery you had.

WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to one of the contact persons listed on page one of this notice. In your request, you must tell us

(1) what information you want to limit;

(2) whether you want to limit our use, disclosure or both; and

(3) to whom you want the limits to apply, for example, disclosures to your spouse.?

• 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 one of the contact persons listed on page one of this notice. 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.

CHANGES TO THIS NOTICE 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 prominently post a copy of the current notice in our organization. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at our offices, we will offer you a copy of the current notice in effect.

COMPLAINTS (You will not be penalized for filing a complaint.) If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services at the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C., 20201. To file a complaint with our organization, contact the person listed on page one of this notice. All complaints must be submitted in writing. Complaints to our organization must be addressed to either of the contact persons listed on page one of this Notice.

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You acknowledge and 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. S:\MED 2003\Mt Auburn ObGyn\Notice of Privacy Practices ? Ml Auburn OB-Gyn.doc

RECEIPT OF NOTICE OF PRIVACY PRACTICES Mt. Auburn OB/Gyn Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. By signing this receipt, you acknowledge that you have reviewed, or have been given the opportunity to review, our Notice of Privacy Practices. As provided in our Notice, the terms of our Notice may change. If we change our notice, you may obtain a revised copy by contacting: Ms.Tina Holtgrefe Mt. Auburn OB/Gyn 2123 Auburn Avenue, Suite 724 Cincinnati, OH 45219 (513)241-4774