NEUROSURGICAL CONSULTANTS, P.A. POLICIES

This document contains two (2) POLICY NOTICES:

A)Notice of Privacy Practices Policy

B) Cancellation Policy for Surgical Procedures

TO OUR PATIENTS: This NOTICE describes how your Health Information (as a patient in this Practice) may be used and disclosed and how you can gain access to your Health Information. This "NOTICE" requirement was created by the Privacy regulations initiated as a result of the Health Insurance Portability and Accountability Act (HIPPA) of 1996. Please review it carefully.

Our Commitment to Your Privacy

We safeguard information during all business practices according to established security standards and procedures, and we continually assess new technology for protecting information. Our employees are trained to understand and comply with these information principles.

In the course of doing business, we collect and use various types of information, like name address and claims information. We use this information to provide service to you, to process your claims and bring you health information that might be of interest to you. We limit who receives information and what type of information is shared.

Keeping Information Accurate

Sharing Information within the Practice

Sharing Information with Other Physicians and Healthcare Workers

Sharing Information with Other Health-related Companies that Work With Us

The Practice DOES NOT SHARE any customer information with third-party marketers who offer their products and services to our patients.

Other Data

Use and Disclosure of Your Health Information in Certain Special Circumstances

1. To Public Health authorities and Health Oversight Agencies that are authorized by law to collect this information.

2. Certain legal proceedings^* in response to a Court or Administrative Order (subpoena).

3. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the Public. We will only make disclosures to a person or organization able to prevent the threat.

4. If you are a member of the U.S. or Foreign Military Forces (including Veterans) ONLY when required by the appropriate authorities.

5. To U.S. Federal Officials for national security or U.S. domestic intelligence activities authorized by law.

6. To Correctional Institutions or Law Enforcement Officials for individuals who are under the custody of Law Enforcement Officials or Institutions.

7. For Worker's Compensation and similar programs.

Your Rights Regarding Your Health Information

1. Communications. You can request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. As an example, you may ask that we contact you at home rather than at your place of business. We will accommodate reasonable requests.

2. Confidential Channel Communications. You may request that we disclose your health information with certain family members or other individuals. You may also request a restriction in our use or disclosure of your health information for treatment, payment or other healthcare operations.

3. Restriction of Information. You have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or payment for your care, such as family members and friends. We are not obligated to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you.

4. Inspection of Records. You have the right to inspect and obtain a copy of your health information that may be used to make decisions about you, including patient medical records and billing records (except for psychotherapy notes.) You must submit your request in writing to NEUROSURGICAL CONSULTANTS, P.A.

5. Amending Health Records. You may ask us to amend your health information if you believe it is incorrect or incomplete and as long as the information is kept by and/or for our Practice. To request an amendment, your request must be in writing and submitted to NEUROSURGICAL CONSULTANTS, P.A. You must provide us with a valid reason that your request for this amendment.

6. Right to a Copy of This Notice. You are entitled to receive a copy of this Notice of Privacy Practices and may ask us to provide you with a copy at any time. Please contact our Front Desk Staff to obtain a copy of this Notice.

7. Right to File a Complaint. If you believe that your Privacy Rights have been violated, you may file a complaint with our Practice or with the Secretary of Health and Human Services. To file a complaint with our Practice, please contact our Practice Administrator at 972.566.6444 for further information. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide Authorization. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this Notice.

B) CANCELLATION POLICY FOR SURGICAL PROCEDURES

NEUROSURGICAL CONSULTANTS, PA is privileged to have the opportunity to provide Neurosurgical treatment to many patients. Our Staff works diligently to accommodate the needs of these patients and to schedule their surgical procedures in a timely manner. This requires careful planning and coordination among our Office, the Hospital facilities, the Operating Room personnel and specialized surgical and technical equipment in addition to other Medical Specialists who will be involved in your care (such as the Anaesthesiologist, Assistant Neurological Surgeon, etc.)

For INTERNATIONAL PATIENTS, a deposit (payable by Certified Check, Wire Transfer^* or Major Credit Card) will be required to secure a surgical date and final payments will be collected at the pre-operative visit.

For DOMESTIC PATIENTS, a deposit (payable by Certified Check, Wire Transfer^* or Major Credit Card) to cover your insurance company's "Deductible" portion will be required to secure a surgical date. In cases where there has been a NEGOTIATED SURGICAL FEE, a deposit is required to secure a scheduled surgery date with final payment collected at the pre-operative visit.

The Cancellation of a Scheduled Procedure results in the failure to serve other needy patients as well as the disruption of the schedules for the Operating room and other Healthcare Professionals.

We, therefore, respectfully request your understanding and cooperation with our Cancellation Policy.

^* Cancellation within 7 Days prior to your procedure date will result in a 50% loss of the deposit. Cancellations made because of a death or illness in the family will be exempt from this policy, and a full refund will be made.

(^*Wire Transfer payments must be received 72 hours prior to scheduling or performing a procedure.)

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This page last edited on 2/14