Forms and Policies

• The length of a follow-up visit is 20-60 min depending on illnesses and procedures needed.

• If needed, we will draw blood and perform a urinalysis in the office – this will save you time and will avoid delays of care. 

• You will be seen by the Provider to review your history, perform a physical exam, review laboratory results, determine your diagnosis, and establish plans for treatment.

• FOR NON-URGENT MESSAGES the office of J. Desiree Pineda, M.D. PLLC accepts various forms of communication including telephone, email, voicemails, and video calls/ telemedicine.

• These methods should NOT be used for emergencies. If you have an EMERGENCY, please call 911, or go to the nearest emergency room.

• Text messages are not permitted. You may receive automated appointment reminders from our electronic health records program.

• We follow all procedures to ensure HIPAA compliance during a telemedicine call or any electronic communications and take diligent steps to maintain your confidentiality through our secured electronic health records (EHR) and communication portals. However, complete privacy and security cannot be guaranteed.

• If you have a new medical issue, or it has been more than three months since your last appointment addressing a specific concern, please request a new appointment. If appropriate, the physician can conduct a telemedicine consultation. The consultation will be billed as a telemedicine visit to your insurance, and co-pays will be charged according to your insurance plan.

  EMAIL GUIDELINES

• You can send inquiries to jdpinedamd24@gmail.com or through the portal Patientfusion.com.

• The office will only email patients at the address provided by the patient. Email addresses will not be distributed to a third party.

• Emails are read Monday through Friday by 3 pm and answered within 24-48 hours of the time it is received, during business hours only. Please note that this excludes holidays and when the office is closed.

• Please attempt to keep emails concise, ideally under 200 words or less. You may scan/attach any relevant information.

• You may email non-urgent requests for prescriptions and referrals. Please refer to the Prescriptions guidelines, Referrals guidelines and Financial Agreement for detailed instructions and fees.

• You may cancel or reschedule appointments by email. If you are rescheduling, please include your preferred dates and times. A fee will apply for cancellations made less than 48 hours before your appointment.  Please refer to our Financial Agreement for fees.

• We will email/scan results, referrals, and documents. Please refer to Financial Agreement for fees.

  TELEMEDICINE GUIDELINES

• Telemedicine is suitable for medical issues that do not require a physical examination, such as reviewing lab results, addressing new or follow-up questions, and handling referral, prescriptions requests or sick visits.

• By law, Telemedicine can only be provided if at the time of the telemedicine appointment the patient is located in the states where the provider has a medical license, these include DC, MD and VA. You will communicate with and see the doctor via video on your device and vice versa. Telemedicine is done through several different platforms, such as FaceTime, Teams, WhatsApp and Zoom.

• If not completed previously, the office will email this authorization form for you to sign. Please e-mail the signed copy of the authorization form back to the office email at jdpinedamd24@gmail.com INDICATING “electronic signature is legally considered the same as a handwritten signature”. If we do not receive the completed form, the provider(s) cannot conduct the telemedicine appointment, and the appointment will be considered as a missed appointment.

• Providers usually call at the scheduled time; however, the call may take place within one hour of your scheduled appointment time. The duration of the call is for 15 to 30 min.

• Providers will call from an office phone. Please note that these phone numbers are not official office numbers and are only used for outgoing calls and do not receive incoming calls or text messages.

• You will be asked to pay your copay before the telemedicine visit. Without payment, we will not be able to proceed with the scheduled appointment. A credit card number will be needed during the scheduling of the appointment.

• When the appointment is entered in the schedule, it is considered CONFIRMED.  If you miss or cancel the telemedicine appointment in less than 48 hours’ notice you will incur a missed appointment fee.  Please refer to financial agreement.

• Please note that you may receive a reminder from Patient Fusion that lists an incorrect time or visit type. Kindly follow the correct time provided at the time of scheduling.

• We recommend that you review your insurance plan guidelines for telemedicine visits. If your insurance denies the visit, you will be responsible for payment, and your credit card will be charged based on your insurance’s allowable charge for the visit.

  I hereby give consent to J. Desiree Pineda, MD, PLLC to communicate by telephone, email, fax, text, video calls and leave voice messages. I understand that electronic communications may have medical information, and full privacy cannot be guaranteed. I have read and acknowledge receipt of these communications guidelines.

Signature of Patient/Representative:_____________________________________________

Patient/Representative’s Name:_________________________________________________

Patient Date of Birth:_____________________________                                                        

Today’s Date:____________________________________

We must emphasize that as medical providers, our relationship both medical and financial is with you the patient, and not with your insurance carrier.

• PATIENT RESPONSIBILITY- You, the patient, is responsible for providing us with a current address, phone numbers, email address, and current insurance information. The patient is responsible for the verification that the office participates with their insurance plan.

• INSURANCE PAYMENT: Your insurance contract is between you, your employer and the insurance company. Please refer to your Policy manual. Our office has contracts and participates with various insurance companies; however, we do not accept all plans offered by the insurance companies. The office contract with the insurance company is for participation in their network and to accept contracted payments. You are responsible for ensuring that the insurance pays for the services within three months of the medical service. After the three months of services provided, if the office does not receive payment, the patient will be responsible for payment of the full amount charged by the office.

• CO-PAYS/PATIENT PAYMENT RESPONSIBILITY:  Payment of co-pays, co-payments and deductibles are collected at the time of service. These payments might be a co-pay which could be a fixed amount, a percentage or a deductible (an annual amount that the patient must pay before insurance starts payments). We retain the right to cancel or reschedule your appointment and/or delay completion of a request if you are unable to pay the copay or outstanding balance at the time of your visit. If the outstanding balance is not paid, we will levy a fee of $15.00 and we will keep a copy of your credit card or check to charge an amount determined by the patient and the office. Any agreement concerning payment arrangements, billing adjustments, billing compromises or modifications of this agreement shall be invalid unless the agreement is in writing and signed by an authorized office representative.

• UNCOVERED SERVICES: If any services or portion of services are denied, not paid by the insurance company, disallowed or considered an uncovered service, the patient agrees to be financially obligated to pay the balance legally due. Fees for services not covered by the insurance company are collected at the time of service. If your insurance company considers J. Desiree Pineda MD PLLC an out of network provider for your treatment, the patient is financially responsible and agrees to pay all uncovered services or any portion of the treatment that the insurance company does not cover.  The patient agrees and is obligated to obtain referrals, preauthorization or precertification process, but it does not create a waiver for payment responsibility. 

• LATE PAYMENT FEE: Our billing company mails monthly statements. If payment is not received within 30 days, a monthly $35.00 late fee will be assessed until payment is made.

• APPOINTMENTS: At the time of booking, the appointment is considered “CONFIRMED”. To accommodate patients with emergencies or patients waiting for an appointment, we kindly request 48 hours’ notice if you are unable to keep your appointment. Cancellations made less than 48 hrs. prior to the appointment or missed appointments will result in a $50.00 fee. This policy includes same or next day appointments.

• PRESCRIPTIONS/REFILL/REFERRAL FORMS: At the time of your visit, we will provide you with referrals and prescriptions needed until your next appointment. During your visit we can print, fax, or send prescriptions to the pharmacy. There is a $15.00 fee per prescription or referral for re- issuing, faxing, or emailing prescriptions, forms or referrals that have already been provided. If you need a new prescription or a new referral, please schedule an appointment.

• FORMS/LETTERS: Please bring any forms and/or instructions at the time of your visit. The patient will incur a minimum charge of $25.00 to complete a form or write a simple letter. We require pre-payment of these services. If the form or letter requires additional follow-up or review of medical records, we will inform you of any additional charges. Please allow 10-14 business days for completion of letters and forms. These forms cannot be completed during an office visit or as a walk-in service.

• RETURNED CHECKS/CREDIT CARD DENIALS: If payment by check does not clear due to insufficient funds or your credit card is denied, your account will incur a fee of $45.00 to cover the bank and credit card company fee.

• PHONE OR EMAIL CONSULTATIONS: The providers do not address a new medical problem without a visit or if it has been three months after a problem was addressed. We will request that the patient schedule a new appointment. If appropriate, the physician will perform a telemedicine consultation. Copayment or deductible payment is expected prior to the consultation, and your insurance will be billed for the consultation.

• PREAUTHORIZATIONS: We consider the preauthorization process unnecessary and causes delays in patient care.  The process can take 20-60 minutes to complete. The processing fee for preauthorization starts at $50.00. If the preauthorization process requires additional follow-up, appeal or review of medical records, we will inform the patient of any additional charges.

  We accept cash, check or credit card payments. A processing fee will be charged for credit cards.

  In this form the term “the patient” refers to and is interchangeable for “you or I” as the person responsible for payment. The term “Insurance company” refers to your medical insurance company or Medicare health care insurance.

  Your signature indicates that you have read. understand, and agree with the policies and your financial responsibilities to this office. Thank you.

Signature of Patient/Representative:_____________________________________________

Patient/Representative’s Name:_________________________________________________

Patient Date of Birth:_____________________________                                                        

Today’s Date:____________________________________

HIPAA Notice of Privacy Practices

The Privacy Rule implements the requirement of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This is a summary of the key elements, to view the entire rule, please go to www.hhs.gov/ocr/hipaa. Our organization is dedicated to maintaining the privacy of your individually identifiable health information. This Notice describes how medical information about you may be used and disclosed and how you may obtain access to this information. The terms of this Notice apply to all records containing your health information that are created or retained by our organization. Please review it carefully. You have the right to obtain a paper copy of this Notice upon request.

Patient Health Information

Under federal law, patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment related to current, past and future physical or mental health medical information. Your health information also includes payment, billing, and insurance information.

How We Use Your Health Information

We use health information about you for treatment, to obtain payment, and for health care operations, including administrative purposes and evaluation of the quality of care that you receive. We are permitted to use or disclose your health information, even without your permission, for the following purposes:

• Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians and other members or business associates involved in the treatment team will record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, such as pharmacists who are filling your prescriptions, to other healthcare providers who are involved in your care and to authorized family members who are helping with your care.

• Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payment from your health plan.

• Healthcare operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment and to assess the care and outcomes of your case, teaching, call your name at the office or by phone, and others in order to perform the business and medical activities needed for your care.

Special Uses

We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions.

Other Uses and Disclosures with or without consent

We may use or disclose identifiable health information about you for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out health information, without your permission, for the following purposes:

• Required by Law: We may be required to report gunshot wounds, suspected abuse or neglect, domestic violence or similar injuries and events.

• Research: We may use or disclose information for approved medical research.

• Public health activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and other similar information to public health authorities; for example for disease control, injury, and disability.

• Health oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.

• Judicial and administrative proceedings: We may disclose information in response to an appropriate subpoena or court order.

• Law enforcement purposes: Subject to certain restrictions, we may disclose information required by law enforcement officials.

• Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.

• Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

• Military and special government functions: If you are a member of the armed forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes or foreign activities if you are a member of foreign military services.

• Workers’ compensation: We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness.

• Business associates: We may disclose your health information to business associates or third parties that we have contracted with to perform agreed upon services. We do not engage in selling your health information, however if we do, we will obtain your written authorization before we are permitted to sell your health information. In all other situations, including marketing activities, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

• Organ donations, emergency treatment, when barriers of communication exists, and reporting to the FDA.

  Authorized Uses and Disclosures that need your Consent.

• Some uses and disclosure needs your permission. You can revoke your authorization to disclose in writing anytime, except for issues that the office and providers have already taken action. If you are not present or not able to agree or disagree to disclose medical records, the provider may need to determine whether the disclosure is in your best medical interest.

• Psychotherapy notes disclosure needs your written permission except if use for treatment, medical training, for legal proceedings, for government agencies or public safety concerns.

• Any marketing communication that includes you to describe a health product, participation in a health care network or services that encourages the purchase or use of a product or services.

  Your Rights and Access

• Individual Rights: You have the following rights with regard to your health information. Please contact the office for exercising these rights.

• Request restrictions: You may request restrictions in writing on certain uses and disclosures of your health information. You have the right to restrict disclosures of your health information to family members or friends, to your health plan for payment and health care operations purposes (and not for treatment) if the disclosure pertains to a health care item or service for which you paid out-of-pocket in full. If requesting a restriction for a health care item or service for which you paid out-of-pocket in full, we will honor your request, unless the disclosure is necessary for your treatment or is required by law. For all other restriction requests, we are not required to agree to such restrictions.

• Confidential communication: You may ask us in writing to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.

• Inspect and obtain copies: In most cases, you have the right to look at the records in the presence of an employee, however you cannot make changes on your records. You can obtain a copy of your health information. An administrative fee may apply. We have the right to deny your request.

• Amend information: If you believe that information in your record is incorrect, or, important information is missing, you have the right to request that we correct the existing information or add the missing information. Amendment requests must be made in writing. In certain cases we may deny your request. You can file a letter of disagreement and we will provide you with a written denial if appropriate.

• Accounting or disclosures: You may request a list of instances where we have closed health information about you for reasons other than treatment, payment, or health care operations.

• Breach notification: We are required to notify you in the event of a breach of your unsecured protected health information, and will do so accordingly.

Our Legal Duty

We are required by law to protect and maintain the privacy of your health information, to provide this notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the notice currently in effect.

Changes in Privacy Practices

We may change our Privacy Practices at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the waiting area and website. You can also request a copy of our Notice at any time. For more information about our privacy practices, please contact the office.

Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about your records, you may contact the office. You also may send a written complaint to the U.S. Department of Health and Human Services. You will not be penalized in any way for filing a complaint.

Personal Representatives and Minors

We will treat an individual that you have designated in writing to be your personal representative the same as you. In most cases, the parents are the personal representative of a minor and can exercise the rights of the minor. Except, if the provider has a reasonable belief that the representative may be abusing, neglecting, or could endanger you.

I acknowledge receipt and understanding of the HIPAA Privacy notice.

Signature of Patient/Representative:_____________________________________________

Patient/Representative’s Name:_________________________________________________

Patient Date of Birth:_____________________________                                                        

Today’s Date:____________________________________

• Office providers will provide after-hours consultations/telemedicine or phone calls for an urgent medical problem or concern.

• Occasionally, another provider will cover for after-hours medical care.

• Please call the office phone number to obtain the phone number to call for urgent concerns only.

• If you have an emergency, please call 911 or go to the nearest emergency room.

• If you have an urgent medical problem. Please do not send emails or messages through the portal. Emails or messages are not checked during non-business hours.

• For after-hours charges, please refer to the Financial Agreement.

• Insurance plans are increasing the number of prior authorizations needed for prescriptions and procedures. We consider the Preauthorization process unnecessary and believe it causes delays in patient care.

• Usually, the insurance uses automated or printed forms requesting information about the patient and treatment.

• Each preauthorization form or process can take 20 to 60 min to complete.

• The insurance company may take 1-2 weeks to answer a request.

• Sometimes, the preauthorization must be done by the provider only or may require extra documentation, phone calls or repeated submissions – In this case, an extra processing fee will be incurred.

• It is the patient’s responsibility to be informed of the medications covered by the insurance company and which medications may require preauthorization. Each insurance plan has their own formulary, which changes frequently. The office does not have access to the insurance formularies and due to time constraints, the staff is not able inquire about alternative medications.

• If the insurance denies a pre-authorization or the patient prefers not to proceed with the preauthorization process, the pharmacy or insurance company should provide the patient with an alternative medication from the same class of medication that does not require preauthorization.

• The provider will provide a prescription for an alternative medication, if it is an appropriate replacement.

• Please refer to the Financial Agreement for fees incurred.

• Information needed: When requesting a prescription or refill please include, your name, Date of birth, contact phone number, the name and dose of medications needed, and the pharmacy name, address, and phone number. To receive a prescription, you must be up to date in your follow up visits as determined by the provider and as indicated in your chart.

• Non Urgent Prescription Refills: All prescriptions refills will be provided during an appointment only. The prescription includes a supply for 90 days with or without refills, except for short term medications. If you need a non-urgent prescription, please send a written request by email or through the patient portal. The office will charge a processing fee for a short-term supply, for afterhours prescriptions or for reissuing prescriptions.

• Urgent Refills with or without a Scheduled Appointment: Please schedule a follow up appointment before running out of medications. We may schedule a telemedicine appointment for prescription refills and will also schedule an in person follow up visit.  We will send a short supply of the medication till your next appointment.  For prescriptions without a visit, the office will charge a processing fee for a short-term supply, for afterhours prescriptions or for reissuing prescriptions.

• Pharmacies Request for Prescriptions: We DO NOT accept pharmacies requests from pharmacies for refills, this is due to many unnecessary pharmacy requests.

• Processing Time of Prescriptions: Prescription requests are filled during business hours and are addressed within two (2) business days. Only urgent prescriptions will be refilled after business hours.  Please pick up your prescription at the pharmacy within three (3) days after the prescription is sent.  The pharmacy may place the medication back on the shelves, and the prescription will be lost in their system.  The office will charge a processing fee for a short-term supply, for after-hours prescriptions, or for reissuing prescriptions.

• Pharmacy notifications: If you do not receive a notification that the prescription has been filled, before calling the office, please contact the pharmacy for an update. If the pharmacy indicates that we are not responding or that we have denied a request, please contact the office for clarification. Please check that you are in need of the prescription before contacting the office.

• After-hours Prescriptions: Only urgent prescriptions will be refilled after business hours. The office will charge a processing fee for a short-term supply, after hours prescriptions or for lost prescriptions.

• Controlled Substance medications and Antibiotics: Narcotics, any medication considered controlled substance, and antibiotics will only be prescribed during an office visit.

• Prescriptions not covered by your insurance: Due to frequent changes of prescription coverage, the office cannot keep up with all insurance formularies. The patient is responsible for contacting the insurance company or pharmacy if you prescription is denied by your insurance. The pharmacy or insurance provider should provide an alternative medication.  If medically appropriate, we will send a new prescription.

• Pre-authorization: We do not agree with preauthorization of medications or of services. The Prior Authorizations process is unnecessary and causes delays in patient care. To contain cost, insurance companies are requiring preauthorization of certain medications.  The office does not have a list of medications that require preauthorization.  Due to the complex and lengthy time involved in this process the office will charge a processing fee. If the preauthorization process requires additional follow-up, an appeal or review of medical records, we will inform the patient of any additional charges.  Please refer to Preauthorization Guidelines and Financial Agreement for details.

• Automatic refills: To avoid mediations error, the office does not recommend automatic refills at the pharmacies. The provider will decide how many refills you will need till your next appointment.

• Please refer to the Financial Agreement for fees.   

• When an appointment is entered in the schedule, it is considered CONFIRMED.

• Failure to appear at or cancellations less than 48 hours prior to your scheduled appointment will result in a cancellation or missed fee. Please refer to the Financial Agreement for charges.

• Cancellations may be done by emailing jdpinedmd24@gmail.com or by calling the office at (202) 828-0935

• Referrals are only provided during an office visit.

• For a new medical problem. Please schedule an appointment to evaluate and determine if a referral is needed.

• If you have not been seen within the past six months, a medical visit is required for re-evaluation, and to write the referral.

• Patients whose insurance plans require referrals to see a specialist must receive a Referral Form from our office. We are not responsible of any denied claims arising from failure to obtain a referral or preauthorization.

• It is the patient’s responsibility to know if they need a referral and whether the specialist is in their insurance network.

• We only use the forms from our electronic medical records and do not use insurance forms.

• Our medical records do not allow to back date referrals.

• Please bring your referral to your appointment. If we need to reissue or resend a referral a processing fee will be assessed. Please refer to our Financial Agreement.

• When you request a referral, please include the name of doctor, the reason for the referral and any procedures, if appropriate.

• Within two weeks of the appointment or of a procedure ordered by the provider, the office will provide a written interpretation.

• Occasionally, the laboratories or other offices do not send the reports to us.

• If you have not received a note or phone call from the office within two weeks of your tests, please send us an email or call us to inquire as to the status of your results.

If you have any questions about billing, please contact the Administration office at 202-828-0935 or email at jdpinedamd24@gmail.com.

Patientfusion.com offers patients secure access 24/7 to their medical records including tests, the ability to request an appointment, use of secure messaging with the provider and staff and much more. 

We will provide information on how to create an account and a temporary password which will be good for 36 hrs. We encourage all patients to create an account with a secure password

Please keep password in a secure place, because of security reasons is not easy to replace the password.

You will be able to see your profile information without a password, but will not be able to see results or communicate with the provider.

D.C. Official Code § 3–1210.12 

In the District of Columbia, the cost of medical records includes a search and handling fee, a per-page fee, and actual cost for postage and handling if mailed. The search and handling fee is a flat amount, and the per-page fee varies depending on whether the records are electronic or non-electronic. The District of Columbia Department of Health adjusts these fees annually based on changes in the Consumer Price Index. 

Medical records are the property of the practice.

You have the right to full access to your medical records.

To obtain a copy of your medical records please email the office with your request and we will send you a Medical Records Request Form.

We require completion of our own Release of Medical Records Form prior to processing the request. 

The cost to obtain a copy of medical records is determined by DC law and changes every year.

The District of Columbia Law 3-1210.12 outlines charges for medical records. “A health care entity may require an authorized person to pay:

(1) For a personal medical record that is produced in an electronic format:

(A) A search and handling fee of $24.34 , even if no personal medical record is located; and (B) A per page fee not exceeding 0.70 cents; provided the total amount shall not exceed $92.08.

(2) For any personal medical record that is produced in a non-electronic format:

(A) A search and handling fee of $24.34, even if no personal medical record is located; (B) A per page fee not exceeding 0.93 cents; and (C) The actual cost for postage and handling.

By law, we can deny your request to see or obtain a copy of your medical records, but only for a few reasons.  For example, if your provider believes that letting you see your records might physically endanger you or another person.

J. Desiree Pineda M.D. PLLC. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. J. Desiree Pineda M.D. PLLC. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

J. Desiree Pineda provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Written information in other formats (large print, accessible electronic formats, other formats)

J. Desiree Pineda M.D. PLLC. provides free language services to people whose primary language is not English, such as:

• Information written in other languages

• Spanish speaking staff

If you believe that J. Desiree Pineda M.D. PLLC. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex you can file a grievance in person or by contacting the office by mail or fax or email. If you need help filing a grievance, we have staff available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue SW, Room 509F, HHH Building

Washington, D.C. 20201

1 (800) 368–1019, (800) 537–7697 (TDD)

Your insurance policy is an agreement between you and your insurance company. The policy outlines a package of benefits, including treatment services, procedures, tests, and medications. Covered services are those that the insurance company agrees to pay for, as listed in your policy. Insurance companies determine which tests, medications, and services they will cover. Providers have no control over the insurance company’s understanding of the medical services that patient’s need.

Your policy also specifies the types of services not covered by your insurance company. You will be responsible for paying for any uncovered medical care you receive. It is important to note that a medical necessity is not the same as a medical benefit. A medical necessity is a service or medication that your provider determines is essential for your care, which may or may not be covered by your insurance. A medical benefit is a service or medication that your insurance plan has agreed to cover.

Your provider will make an effort to familiarize themselves with your insurance coverage to ensure they provide you with covered care. However, it is not possible to know every detail of each individual plan. As a patient, you are responsible for understanding your insurance coverage and what is included in your policy.

Many insurance companies require preapproval or preauthorization before covering a specific medication or procedure. However, even if a service is preapproved, the insurance company may still state that preapproval does not guarantee payment. In such cases, the patient will be responsible for the cost.

Remember, your insurance company—not your provider—determines what will be paid for and what will not. Your provider—not your insurance company—makes medical decisions and recommendations based on what is best for your health.

If your insurance company does not cover a test, treatment, or medication, it is often referred to as denying the claim. In such cases, the patient is responsible for paying out of pocket for the services or treatment.

If your insurance company denies a claim, you have the right to appeal the decision. You should familiarize yourself with the insurance appeal process as outlined in your policy manual. If your provider believes an appeal is necessary, they may be able to assist you with the process.

If you have any questions concerning your coverage, please contact your insurance company. A representative can clarify and discuss your benefits with you while addressing any of your concerns.

You have the right to be protected from surprise medical bills, also known as balance billing, in certain situations. These unexpected bills can occur when you receive care from an out-of-network provider or facility without realizing it.

When You’re Protected from Surprise Bills

Federal law prevents out-of-network providers from billing you more than your in-network cost-sharing amount in the following situations:

• Emergency Services – Even if you receive emergency care from an out-of-network hospital or provider, you can’t be charged more than your plan’s in-network rates.

• Certain Non-Emergency Services – If you receive care at an in-network hospital or facility but are unknowingly treated by an out-of-network provider (such as an anesthesiologist or radiologist), you cannot be billed more than your in-network cost-sharing amount.

• Air Ambulance Services – You are protected from excessive charges for out-of-network air ambulance services.

Your Rights Under the Law

• No Surprise Bills – You can’t be forced to pay higher out-of-network costs for covered emergency services and certain non-emergency care at in-network facilities.

• No Balance Billing – Providers cannot bill you for the difference between what they charge and what your insurance pays for protected services.

• Clear Cost Estimates – You have the right to request a Good Faith Estimate of expected charges before receiving care.

• Appeal Rights – If you believe you’ve been wrongly billed, you have the right to dispute the charge.

What You Should Do

• If you receive a surprise medical bill, check your Explanation of Benefits (EOB) and compare it with your provider’s charges.

• Contact your insurance company to clarify coverage and billing.

• File a complaint if you believe you’ve been unfairly charged.

For more details on your rights and protections, visit [official government resources] or contact your state’s insurance department. 

Our office offers a convenient payment to cover pending balances or prepayment of services provided.

The patient's portion is determined by the insurance and explained in your insurance policy. After the visit, the insurance company sends an Explanation of Benefits (EOB) which indicates the amount of the patients yearly deductible, percentage and or co-pay.

 Prepayment of copays, deductibles or coinsurance payment of the visit charges and of any office procedures not covered by insurance is required at the time of visit. Please refer to our Financial Policy for fees.

 If you cannot pay by credit card, we can arrange other forms of  monthly payments. Please inform the front desk to make arrangements.

CONSENT

I hereby consent and allow J Desiree Pineda M.D. PLLC. to charge my credit card for any outstanding balance(s) as indicated by my insurance company or for medical services or procedures not covered by my insurance company. A copy of the receipt will be mailed/emailed to me.

__ VISA

__ MASTERCARD

NAME ON CREDIT CARD:_____________________________________________________

CARD #:_______________________________________________________________

EXP DATE:____________________ #CVV:_______________

PATIENT SIGNATURE:__________________________________________________________

PATIENT’S NAME: _____________________________________________________________

DATE: ________________________