Patient(s) Information

Please include all children on the account.  Any child 18y+ must also complete and sign their own form.

Parent/Guardian Information

Please fill in the full name of the person completing this form. 

If a patient who is 18y+ is completing this form, please enter your full name and phone number; and put SELF under relationship.

Insurance Authorization and Assignment

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor and authorize him/her to furnish information regarding my visits to my insurance carrier for claims processing.

Notice of Privacy Practices

Olney Pediatrics PA

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. Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information.  We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information.  Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure.  We must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time. If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at OlneyPediatrics.org.  You also may ask for a copy of the Notice by calling us at 301-774-4100 and asking us to mail you a copy or by asking for a copy at your next appointment.

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent

We may use and disclose your Protected Health Information as follows without your permission:

For treatment purposes.  We may disclose your health information to doctors, nurses and others who provide your health care.  For example, your information may be shared with people performing lab work or x-rays.

To obtain payment.  We may disclose your health information in order to collect payment for your health care.  For instance, we may release information to your insurance company.

For health care operations.  We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide.  We may disclose your information to students training with us.  We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.

When required by law.  We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies.  For example, we may have to report abuse, neglect or certain physical injuries.

For public health activities.  We may be required to report your health information to government agencies to prevent or control disease or injury.  We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety.

For health oversight activities.  We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.

For activities related to death.  We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial.  We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.

For studies.  In order to serve our patient community, we may use or disclose your health information for research studies, but only after that use is approved by UWM's Institutional Review Board or a special privacy board.  In most cases, your information will be used for studies only with your permission.

To avert a threat to health or safety.  In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.

For specific government functions.  In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs, and for national security reasons.

For workers' compensation purposes.  We may disclose your health information to government authorities under workers' compensation laws.

For fundraising purposes. We may use certain information (such as demographic information, dates of services, department of service, treating physicians, and outcomes) to send fundraising communications to you. However, you may opt out of receiving any such communications by contacting our Privacy Officer (listed below) and your decision to opt-out will have no impact on your treatment.

Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object

In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object:

In patient directories.  Your name, location and general health condition may be listed in our patient directory for disclosure to callers or visitors who ask for you by name.  Additionally, your religion may be shared with clergy.

To your family, friends or others involved in your care.  We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition.  We may release your health information to organizations handling disaster relief efforts.

Uses and Disclosures of Your Protected Health Information That Require Your Consent

The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:

For research purposes.  In order to serve our patient community, we may want to use your health information in research studies.  For example, researchers may want to see whether your treatment cured your illness.  In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes.  Completion of this form is completely voluntary and will have no effect on your treatment.

For marketing purposes.  Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment.  Additionally, without your permission we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.

Of psychotherapy notes.  Without your permission, we will not use or disclose notes in which your doctor describes or analyzes a counseling session in which you participated, unless the use or disclosure is for on-site student training, for disclosure required by a court order, or for the sole use of the doctor who took the notes.

For any other purposes not described in this Notice.  Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice. Your Rights Regarding Your Protected Health Information You have the following rights related to your Protected Health Information:

To inspect and request a copy of your Protected Health Information.  You may look at and obtain a copy of your Protected Health Information in most cases.  You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information which you cannot access by law.  If we use or maintain the requested information electronically, you may request that information in electronic format.

To request that we correct your Protected Health Information.  If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file.  We may deny your request if we find that the file is correct and complete, not created by us, or not allowed to be disclosed.  If we deny your request, we will explain our reasons for the denial and your rights to have the request and denial and your written response added to your file.  If we approve your request, we will change the file, report that change to you, and tell others that need to know about the change in your file.

To request a restriction on the use or disclosure of your Protected Health Information.  You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request.  An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service.  If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations.  We cannot limit uses or disclosures that are required by law.

To request confidential communication methods.  You may ask that we contact you at a certain address or in a certain way.  We must agree to your request as long as it is reasonably easy for us to do so. 

To find out what disclosures have been made.  You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years.  We must respond to your request within sixty days of receiving it.  We will only charge you for the list if you request more than one list per year.  The list will not include disclosures made to you or for purposes of treatment, payment, health care operations if we do not use electronic health records, our patient directory, national security, law enforcement, and certain health oversight activities.

To receive notice if your records have been breached.  Olney Pediatrics will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you.  We will review any suspected breach to determine the appropriate response under the circumstances.

To obtain a paper copy of this Notice.  Upon your request, we will give you a paper copy of this Notice.  If you have any questions about these rights, please contact us. How to Complain about Our Privacy Practices If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you may file a complaint with our Privacy Officer by writing to Richard Tran, MD, 18111 Prince Philip Drive #311, Olney, MD 20832.

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.

We will take no action against you if you make a complaint to either or both of these persons.

How to Receive More Information About our Privacy Practices

If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, Dr. Richard Tran.

Effective Date

This Notice is effective on October 1, 2022.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. I understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices. This signature is only acknowledgement that you have received this notice of our Privacy Practices.

We are committed to providing the best care possible. Understanding your financial responsibility is considered part of your medical management.  Our financial/office policy is an agreement between the providers of the practice and the child's parent, guardian, or responsible party (18+ yrs old). Your understanding of this patient-provider agreement is important to our professional relationship.

Policies
Olney Pediatrics follows the American Academy of Pediatrics recommendations for the vaccination of children. The waiving of certain vaccines, unless medically necessary, is not acceptable for patients in this practice. A parent/legal guardian MUST be present at all well child visits for patients under 18yrs old. 
If you arrive 15 or more minutes late to your appointment, you may be asked to reschedule and the appointment will be considered missed.
Reminder calls/texts are a courtesy and we do our best to make them 1-2 days prior to the appointment. Failure to receive one does not absolve you of your responsibility to keep your appointment.
Please expect 3-5 business days for all forms, referrals, and prescription refill requests.

Insurance
Insurance cards must be available at EVERY visit. Payment for services is due at the time services are rendered except as outlined below. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. It is the responsibility of the patient/responsible adult to provide accurate and timely insurance information. Inaccurate or untimely information provided to the staff that results in denial or non-coverage by your insurance may result in you being responsible for payment.

If we do not participate with your insurance or you have no insurance:
Payment for services is due at the time of service unless arrangements have been made in advance. We will provide you with an itemized bill so that you may submit for reimbursement.

Billing*
We accept, cash, checks and most major credit cards. Outstanding balances are due within 30 days, unless prior arrangements have been made. An additional $10 billing fee will be added to balances more than 60 days past due. An additional $10 billing fee will be added to balances that remain outstanding more than 90 days and a final request for payent letter will be issued. Balances not paid in full within 10 days of the date on the final request letter will be issued. Balances not paid in full within 10 days of the date on the final request letter will be forwarded to a collection agency. If your account is forwarded to a collection agency, we will continue to see your child on an emergency basis only for 30 days, giving you time to find a new source of medical care.

Returned Checks*
There is a $35 fee for any check returned to us from your banking institution and your account will be placed on a "cash/credit card only" basis until the balance is cleared.

Missed appointments/late (less than 24hr notice) cancellations*
Missed/late cancellation appointments represent a cost to us, you, and to other patients who could have been seen in the time set aside for you.
A $50 charge, per child, for missed/late cancellations for Well Child/ADHD/Behavioral issue appointments with a doctor.
A $25 charge, per child, for missed/late cancellations for other types of appointments with a doctor or nurse. Your family could be subject to dismissal from the practice for a third or subsequent missed appointments.

After Hours and Weekend/Holiday Appointments*
There may be an additional fee charged for visits occurring on weekends, holidays, before and after hours. We will bill this charge to the participating insurance plan. You may be responsible if your insurance carrier does not cover this charge.

Divorced/Separated Parents
If there is a custody dispute and a parent is not privileged to a patient's information, please provide us a copy of the legal document. The accompanying parent or adult is responsible for payment at the time of service. It is your responsibility to work out the payment of your child's medical care between custodial and non-custodial parent.

Newborn Enrollment
It is essential that you contact your insurance plan or the policy holder's HR department to enroll your newborn on your policy, within the first 30 days. We recommend doing this within the first few days of your baby being born as it often takes a few weeks for the baby to show up on the plan as a covered member.

Medical Records*
With the signed request from the patient (if 18y+), parent, or legal guardian, we will provide you with a copy of your child's medical record. There is a charge of $20 per child. Please allow 2 weeks to complete. Immunization records can be obtained thru the Patient Portal.

Camp/School Forms*
There is a charge of $20 per child for certain forms, each time the doctor has to fill them out. We suggest you keep copies of all forms as they may be good for up to one year of the date of the last physical exam.

*Note: Most of these fees are waived by state law for children enrolled in Maryland Children's Health Insurance Program - Medicaid