PARTNERS IN ENDOCRINOLOGY- DR. JYOTHI MAMIDI JUAREZ

***For our patients with Diabetes:

While we understand managing a chronic medical disease is difficult, we do expect our patients to be equally interested in optimal management of their diabetes. 

We Require: 1)  compliance with medication regimen

2)monitoring sugars as recommended by Dr. Juarez

3) diet/exercise

4) being up to date with labs and follow ups. 

We require patients with a1c over 10% to follow up every 2-4 weeks until sugars are under better control. We require patients with a1c 8-10% to follow up every 4-6 weeks until sugars are under better control.   We are here to work together for the best management of your diabetes.  Except under extenuating circumstances, if labs and follow up are more than a month out of the recommended schedule, you may be at risk of being released from this practice. 

CLINIC POLICIES- READ CAREFULLY

We appreciate the opportunity to take care of your Endocrine needs.

-New patient paperwork (these forms) need to be turned in before we schedule.

We also need pertinent labs/ records before scheduling in order to make the visit go smoothly.

-For New patients, we only allow a ONE time reschedule if notified over 48 business hours. New patient appointments which are cancelled less than 48 hours or no show WILL NOT BE RESCHEDULED. 

-Refills may take 48-72 business hours. Please plan accordingly. If you are overdue for labs and follow up, a one time ONE month refill will be sent. Please make sure labs and follow up are completed prior to the completion of the one month refill. Refills are best obtained by asking your pharmacy to send us a refill request.  DO NOT CALL for refill requests. 

-Please use the patient portal (www.patientfusion.com) for communication. Do not use the admin email. Please limit calls to the office as we are with patients most of the day and can better respond to portal or text messages. 

After hours calls and weekends are only for emergencies. Scheduling/ refill or other issues will only be addressed during business hours.  

-Please note Dr. Juarez uses a Virtual Scribe who is able to listen to the office visit but there is no recording of the visit, no video available. The virtual scribe is considered part of the practice and follows all HIPAA /Privacy rules.  Signing this form indicates agreement to the virtual scribe. 

-For follow up patients, if there is a "no show" or less than 48 hour cancellation, there is a $50 fee to reschedule the appointment. 

-Dr. Juarez is unable to call patients or respond to multiple or long portal messages. Discussions outside of quick questions which can be answered by staff will require a scheduled appointment either telemedicine or in person to address all concerns at once.

-Most follow up patients may need pre-clinic labs. You must be sure to have the labs done early enough so that results are available for the visit; we can also wait to schedule an appointment until labs are in.  We have to cancel an appointment if required labs are not in.  ALL lab results require an appointment discuss. Results are reviewed by Dr. Juarez  at the time of the appointment.  All pre-clinic labs require an appointment to discuss even if normal.  Failure to follow up will assume you will be seeking care elsewhere. 

 

FINANCIAL POLICIES- PLEASE READ CAREFULLY 

 

-Please note copays, deductibles for the visit are due at the time of service. We are not able to offer payment plans or bill later.  

-A staff member verifies all insurances 1-3 days prior to an appointment. This confirms that we are in network, that any necessary referral is in place, and also estimates the patient responsibility of cost for the visit. We will send a secure text to alert you of any expected payment more than a copay (typically due to a deductible). If you feel this is an error, please contact your insurance company BEFORE the appointment to get more clarification.  We expect that you will pay the estimated amount per our insurance verification. Once the insurance processese the claim, IF the patient has paid more than their share, credit will be given back within 4-8 weeks. We are not able to wait for the claim to be processed and collect later.  

-All balances must be paid in full as soon as the insurance claim is processed and  billing statement has been sent.  We will also attempt to collect the balance via phone calls as well as at the time of the next appointment.  

Mutual Respect: 

-Please note our staff is working hard and covering multiple tasks at any given time. DO NOT CALL REPEATEDLY. We have a busy clinic. ANY TASK CAN TAKE UP TO 3 BUSINESS DAYS TO COMPLETE.  IF IT IS  URGENT, YOU MAY NEED TO SCHEDULE A SAME DAY APPT IF AVAILABLE. 

-Please note that rude behavior of any kind is not acceptable and is grounds for dismissal from the practice. We value our employees. We value our patients. We expect mutually respectful communication. NO EXCEPTIONS. 

Please sign below to acknowledge the clinic polices and procedures. 

By signing below, you acknowledge that you have received the notice of privacy practices prior to any service being provided to you by the practice and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below.  The Notice of Privacy Practices is available online or a copy may be emailed to you or you may review the paper copy in the clinic. 

Introduction
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of
the following:
 Patient medical records
 Medical images
 Live two-way audio and video
 Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
 Improved access to medical care by enabling a patient to remain in his/her phycisian office (or at aremote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
 More efficient medical evaluation and management.
 Obtaining expertise of a distant specialist.

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of telemedicine.
These risks include, but may not be limited to:
 In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
 Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
 In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
 In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My ophthalmologist has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my ophthalmologist of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions
have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize Dr. Juarez to use  telemedicine in the course of my diagnosis and treatment.

To comply with the Telephone Consumer Protection Act (TCPA) our office is required to receive consent for sending appointment reminders and messaging by SMS mobile texting or voice telephone calls. 

 Please indicate your consent below by checking the box by each statement you agree with and then select which method of communication you prefer.

 If you have any questions please call Partners in Endocrinology at (713) 929-0043.

You may update and/or change your preference of how to contact you at anytime by completing a new consent form or by putting your request in writing and submitting it to Partners in Endocrinology

Please read this entire form before signing and complete all the
sections that apply to your decisions relating to the disclosure
of protected health information. Covered entities as that term is
defined by HIPAA and Texas Health & Safety Code § 181.001 must
obtain a signed authorization from the individual or the individual’s
legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for
disclosures related to treatment, payment, health care operations,
performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other
form that complies with HIPAA, the Texas Medical Privacy Act, and
other applicable laws. Individuals cannot be denied treatment based
on a failure to sign this authorization form, and a refusal to sign this
form will not affect the payment, enrollment, or eligibility for benefits

 

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Dr. Jyothi Mamidi Juarez- Partners in Endocrinology

350 N. Texas Ave. Suite A-2

Webster, TX 77598

fax: 713-929-0044

phone: 281-619-7092

 

Reason for request: Ongoing medical care.  

What information can be disclosed: The last 2 clinic notes, last 2 sets of labs, any pertinent Endocrine related imaging or other specified request below. 

 

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional): Month _________ Day __________ Year _________
RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.