Office Policies and Procedures

We appreciate the confidence you have shown by choosing our office to provide medical care to you and your family. We make every effort to give you the best possible care. In order to achieve this, we ask for your assistance in the following clinic policies.

APPOINTMENTS
Appointments are required to address any/all issues and concerns. Regular office hours are Monday through Friday from 9:00 am – 6:00 pm with lunch from 12 pm – 1:00 pm (hours may vary from time to time). We reserve some appointment times for same day "sick" visits every day. We work hard to accommodate requests for same day appointments, but are not always able to do so. New patients must arrive 30 minutes prior to their appointment time. If you are an established patient, please arrive 10 minutes prior to your appointment time. If you arrive late, we may need to reschedule your appointment.

If you are unable to keep your scheduled appointment, please call our office 24hrs hours ahead to cancel so that your appointment time can be made available to other patients. It is our policy that if you do not show for 3 appointments you will be notified by mail that you will be discharged from the practice. Phoenix Family Medical Clinic reserves the right to bill $25.00 for No-Show appointments.

TEST RESULTS
Our medical assistant will usually contact you by phone regarding your test results to schedule an appointment for follow-up. Due to HIPPA Law we are unable to disclose any medical information with you or any other member of your family. If you have not heard from our office within 15 business days, please contact our office.

MEDICATION REFILLS
We require 72 hours notification for all refill requests. Please do not allow yourself to run out of medication. Your provider requires advance notice, as he/she needs to evaluate your medical records. Narcotic medications will NOT be refilled without an office visit.

REFERRALS
All referrals require an office visit. When your provider wants you to be referred to a specialist, it will take up to 10 business days for completion. If it is an urgent referral, it will be completed within 48 hours. You will receive all the information you need by mail or phone so that you are then able to call and schedule your appointment. If your specialist requires additional visits, it is your responsibility to verify that the specialist is contracted with your insurance prior to your visit.

MEDICAL RECORDS
For all medical record requests, a release form will be provided and must be signed by the patient. Please allow 15 business days to process your request. Your records may be faxed to another physician's office OR made available for you to pick up in our office, Please note: If you are picking up records from our office there is a minimum charge of $15.00 for up to 30 pages.

PHYSICIAN PHONE CONSULT
Our providers do not usually consult patients over the phone. If this becomes a necessity which is not a medical emergency, we reserve the right to charge you a consultation fee (most insurance plans do not cover phone consultations, so therefore this charge will be your responsibility).

INSURANCE
It is the patient's responsibility to understand their insurance plan benefits. We will try to assist you when possible with what is and is not covered. The patient is responsible for services/items that the insurance does not cover.

PAYMENTS
The patient is responsible for payment of each office visit. If you have insurance, our billing department will file the claim with them as a courtesy. Please have your insurance card with you at each visit. Co-payments and payments are always required on the day of service. If you do not bring your payment with you, we reserve the right to reschedule your appointment. Patients without insurance will need to pay for their service on the day it is rendered. Please pay with cash, credit or debit card. We do not accept checks. A 33% fee will be added to accounts that are sent over to collections.

AFTER-HOURS EMERGENCIES
If you have a true medical emergency, please call 911 or go to the nearest emergency room to receive medical assistance immediately.

Patient Information/Informacion del Paciente

Spouse or Emergency Contact Information (or Parent/Guardian if Patient is Child)

Medical Insurance Information/Informacion del Seguro Medico

Health History Questionnaire

Personal Health History

Health Information and Personal Safety

Family Health History

Other Problems

Health Information and Personal Safety

Health Information and Personal Safety

Health Information and Personal Safety

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

You may refuse to sign this Acknowledgement

Patient Record of Disclosure

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's home.

Patient Authorization to Disclose Personal Information

Oxycodone/Narcotic Pain Medication Guidelines

From: Dr. Napoleon Ortiz, MD

• This clinic follows strict rules on prescribing Narcotic Pain medication.
• We discourage all long term use of narcotic pain medication including Oxycodone.
• If you are here just to seek narcotic pain medication or Oxycodone, please be aware that this clinic will not prescribe those medications.
• All Oxycodone/ narcotic pain medication prescriptions are FINAL. There will be no refills at all, under no circumstances.
• We believe that Narcotics Pain killers like Oxycodone do not heal or cure anything.

If you do not agree with these guidelines, we request that you let the front office person know, so she cancels your appointment. We thank you for your patience in reading this memo.