General Insurance Information: We try to work with as many insurance plans as we feel comfortable, and we will do our best to bill your insurance company quickly and correctly. We require that you provide us with a current copy of your Medical Insurance Card at each office visit. Without your current card, we may not bill your insurance correctly.
Your Professional Medical Relationship with CTFP: Our professional staff provides medical services to you. You are responsible for the cost of those services.
Your Professional Medical Relationship with your Insurance Company: Medical insurance is established to help you cover the costs of your medical care. Your insurance company was chosen by either you or your employer. Many employers ask for contracts with specific inclusions and exclusions. We will not necessarily know what these are. Please understand that it is your responsibility to know your insurance plan and its rules.
Insurance Co-pay: Insurance companies have established co-pays to discourage clients from seeking medical care. This amount is set by the insurance company and is payable at the time of service. We are required to charge this fee each time we see you. We charge a billing fee of $15.00 if the co-pay is not paid at the time of service.
Laboratory Tests and Pathology: We use labs that are reputable and provide good service. Some insurance companies have contracts with special labs. We will send your lab tests to the appropriate lab if we are aware where to send it, so please be sure that you know any special rules of your insurance plan. Mistakes can be costly, as the tests have already been done by the incorrect lab when the error is recognized.
Medicare: We have chosen to OPT OUT of Medicare. This means that we can’t bill Medicare for your visit, and you can’t bill Medicare yourself. We also can’t order lab tests or X-Rays, or prior authorize non-formulary medications. We apologize and we will help you find a physician who does bill Medicare insurance.
If you have Medicare insurance and choose to be seen in our office, you must pay cash for your visit. At this time, we are still able to prescribe medications and have Medicare insurance cover them if the medications are on your Medicare insurance formulary. This could change at any time.
Medicaid: We are providers for traditional State and Community Care Medicaid only.
For patients with Nontraditional State Medicaid, Healthy U, PCN, Molina, etc., we are not contract providers and cannot see you because we bill their plans.
Patient Privacy Consent: A “Privacy Rule” was created by the Department of Health and Human Services to insure that personal health information is always protected. Please understand that we respect your privacy and will do our best to protect it. Please review our “Notice of Privacy Practices” below for further information.
If you wish to change any of the provisions on how we may use or disclose your protected health information, you may do so in writing but we will have to agree to it prior to providing medical service to you.
You may also refuse to have us release any information, but you must pay cash at the time of service as we will not be able to bill any insurance company for your visit.
By signing this consent form, you acknowledge that you have read a copy of our “Notice of Privacy Practices,” and that you consent to Cherry Tree Family Practice using and disclosing your protected health information for the purposes of treatment, payment, health care operations and as otherwise outlined in the “Notice of Privacy Practices”.
PLEASE NOTE: Our Notice of Privacy Practices may be changed from time to time to conform to applicable standards and laws. In that event, this consent will apply to future revisions. You may obtain a copy of the latest Privacy Practices HERE or at any time from our office.
Patient Financial Agreement: (Printable Version Link)
ALL CHARGES FOR MEDICAL SERVICES ARE DUE AND PAYABLE AT THE TIME OF SERVICE.
Medical Insurance: We have contracts with many insurance companies Accepted Insurance Companies, and we will bill them as a service to you and your family. As the responsible party, you are responsible if your insurance company declines paying for the services for any reason.
The person signing as the Responsible Party must present Cherry Tree Family Practice (CTFP) with the following items:
• Supply current address and phone number for the patient and the responsible party.
• Present for our records all current insurance cards prior to each visit.
• Verify that all of your personal and insurance information is current and correct and sign our demographic data sheet.
• Pay any required Co-pay at the time of the visit.
• Pay any additional amount owing within 30 days of receiving a statement from our office.
(When CTFP receives an explanation of benefits from your insurance company, any amounts that you need to pay will be billed to you).
When coming in the office for a Pre-mission Physical Exam, please review the following information carefully so that you come prepared for your office visit. This information outlines all items the physicians will need in order to complete your mission forms when you are here.
• Your Bishop will give you a packet of missionary forms. You are required to complete the medical history form in this packet prior to seeing the medical provider, and you will need to bring this form with you to your appointment. We cannot see you if you do not have this form completed.
• If you have Medical Insurance, you will need to bring your card (or a copy) with you to your appointment.
• If you do not have insurance, please call our office for the current cash price for a missionary exam.
• You will be given a TB test when you are in the office. This test requires that you come back into the office to have it read two or three days after your appointment. Because of this, we suggest that you do not schedule missionary exams on Thursdays.
• A urinalysis is required, so please come prepared to leave a urine sample when you are here.
• We need all of your Immunization records for the appointment, so please bring them with you. We will not guess which immunizations you need. If you do not have your records, we will not give immunizations when you have your exam. As soon as you locate your records and determine if immunizations are covered by your insurance, (we suggest going to the County Health Department for immunizations if your insurance doesn’t cover them as they will be less expensive there), come in and we will administer any needed immunizations.
• The church now requires all missionaries to have immunizations for hepatitis A and hepatitis B. Coverage for these immunizations are insurance plan specific, meaning that you will need to verify with your Insurance Company before you are seen to find out if these are covered. We will not administer the vaccines when we see you unless we know it is covered of if you choose to pay cash for them in advance.
• We understand this is a lot of information, but we have found that if we do not provide this checklist, we cannot complete the forms as required when you are here.
Medical Arbitration: (Printable Version Link)
We firmly believe that arbitration is a fair way of resolving medical liability disputes that will help preserve the availability of quality health care and high-risk medical procedures here in Utah. We request you sign the arbitration agreement.
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
As a valued patient of Cherry Tree Family Practice (CTFP), you are entitled to receive notice of our privacy practices. This Notice explains how we use and disclose your personal information, and the choices and rights you have with regard to how your personal health information may be used and disclosed.
Introduction. When you become a patient of CTFP you provide us with information about yourself and your health. Each time you visit us, another record of your visit and the services you received, is made. Your record – the medical record – is the information that we use to plan your medical care, provide treatment and receive payment for our services. Your medical record contains personal information about you and your treatment, and is protected by federal law.
Our Responsibilities. CTFP is required to maintain the privacy of your Protected Health Information (PHI) and to provide you with a notice about our legal duties and privacy practices with respect to your PHI. Any time we use or disclose your PHI, we are required to follow the terms of this Notice.
We reserve the right to change our privacy practices and to alter this Notice according to those changes. In the event that our Notice changes, and you request a copy, we will provide you with the revised Notice.
How We Use And Disclose Your Protected Health Information (PHI)
• Uses and Disclosures with Consent. As a condition of receiving treatment, you will be asked to sign a written consent form for use of your PHI for treatment, payment and health care operations as explained below:
• For Treatment. We will use and disclose your PHI to plan, provide and coordinate your health care services. For example, we may provide your PHI to a physician we have referred you to in order to ensure the physician has the necessary information to provide your health care.
• For Payment. We will use and disclose minimal PHI in order to obtain payment for health care services we have provided to you. For example, we may use and disclose your PHI to obtain payment from your health insurer.
• For Health Care Operations. For example, we may use or disclose your PHI to perform risk assessments and other administrative tasks to monitor the quality of care that we provide.
• Uses and Disclosures With Authorization. For uses and disclosures of your PHI not involving treatment, payment and health care operations, we will receive your written authorization prior to using or disclosing any personal health information (unless we are required or permitted by law to use or disclose your information as set forth below). You have the right to revoke any authorization previously granted.
Uses and Disclosures Without Consent or Authorization:
• Emergency Treatment. We may use or disclose your PHI for treatment, payment and health care operations without consent or authorization for situations of emergency treatment, when we are required by law to treat you but cannot obtain your consent, and when we are unable to obtain your consent due to communication barriers.
• Directory. Occasionally people will call and ask for you by name and if you are still in our office being seen. Unless you notify us to the contrary, we may disclose this information to the requestor.
• Notification of Family of Close Friends. We may use or disclose your PHI to notify a family member, personal representative or another person responsible for your care, provided you have the opportunity to agree or object to the disclosure. If you are unable to agree or object, we may disclose this information as necessary if we determine that it is in your best interests based upon our professional judgment.
• Required by Law. We may use or disclose your PHI to the extent that we are required by law to do so. The use or disclosure will be made in full compliance with the applicable law governing the disclosure.
• Public Health Activities. We may use or disclose your PHI for public health activities and purposes in compliance with applicable laws for the purpose of controlling disease, injury or disability; reporting child abuse and neglect; reporting information about products and services under the jurisdiction of the United States Food and Drug Administration; alerting authorities of persons who may have been exposed to a communicable disease; and reporting information to your employer as required under Workers’ Compensation laws.
• Health Oversight Activities. We may make disclosures of your PHI to a health oversight agency charged with overseeing the health care industry.
• Marketing. We may contact you to remind you of appointments or to provide you with information about treatment alternatives or other health-related products or services.
• Research. We may use or disclose your PHI for research purposes when such research has been approved by an institutional review board that has reviewed the research to ensure the privacy of your PHI.
• Legal Proceedings. We may disclose your PHI in any judicial or administrative proceeding in response to orders, subpoenas and other valid legal process.
• Law Enforcement. We may disclose your PHI to law enforcement officials in compliance with applicable law.
• Abuse or Neglect. We may disclose your PHI to public authorities authorized by law to receive reports of child abuse, neglect or domestic violence.
• Limited Government Functions. We may disclose your PHI to certain government agencies charged with special government functions (e.g., the U.S. Military, or the Department of Professional Licensing).
• Funeral Directors. We may disclose your PHI to funeral directors in accordance with applicable law.
• Organ Procurement. As allowed by law, we may disclose your PHI to organ procurement organizations for organ, eye or tissue donation purposes.
• Coroners. We may disclose your PHI to a coroner or medical examiner in accordance with applicable laws.
• Health and Safety. We may disclose your PHI to prevent or lessen a serious threat to a person’s or the public’s health and safety.
• Workers’ Compensation. We may disclose your PHI in accordance with workers’ compensation laws.
Your Rights. You have the right to the following:
• Right to Receive a Copy of this Notice. Upon request, you have the right to receive a paper copy of this Notice by calling, e-mailing or faxing your request to CTFP.
• Right to Receive Further Information. You have the right to contact our Privacy Officer and request additional information about our privacy practices, your privacy rights, or disagree about a decision we made about your PHI, or if you believe that your privacy rights have been violated. If desired, you may make a formal complaint mailed and addressed to our Privacy Officer.
• Right to Inspect and Copy Your Health Information. Upon request, you have the right to access and obtain a copy of your health information maintained by us.
• Right to Amend Your Health Information. You have the right to request that we amend your health information maintained in your medical record. We will comply with your request in the event that we determine the information that would be amended is false, inaccurate or misleading.
• Right to Request Additional Restrictions on Uses and Disclosures of Your Health Information. You have the right to request that we place additional restrictions on how we use or disclose your PHI. While we will consider any request for additional restrictions, we are not required to agree to your request. This request should be written and addressed to our Privacy Officer.
• Right to Request an Accounting of Disclosures. You have a right to request an accounting of the disclosures made by us of your PHI. For each disclosure, the accounting will include the date the information was disclosed, to whom, the address of the person or entity that received the disclosure (if known), and a brief statement of the reason for the disclosure. A written request for an accounting of the disclosures must be made in writing and addressed to our Privacy Officer.
• Right to Request Confidentiality in Certain Communications. You have the right to request to receive your health information by alternative means of communication or at alternative locations. We will accommodate any such reasonable written request made on your behalf. This written request should be addressed to the Privacy Officer.
• Right to File a Complaint. If you believe your privacy rights have been violated, you also have the right to file a written complaint with the Office of Civil Rights of the United States Department of Health and Human Services.
• Website (Internet). Our website privacy notices, such as the one located here, contain additional information particular to website use. Please pay careful attention to those notices if you transmit personal information to CTFP over the internet.
• Privacy Officer. To contact the Privacy Officer, please address all requests to: Dr. William Preston, Cherry Tree Family Practice, 155 North 400 West, Orem, UT 84057
Effective Date of this Notice. This Notice is effective as of April 15, 2017.