Terms and Conditions of Registration, Medical Services and Financial Agreement
Beach House Pediatrics, PC (BHP) is a pediatric medical practice that provides telehealth services through online video visits.
Consent to Treat: I consent to medical treatments or procedures, medications, laboratory procedures, x-ray examinations, taking digital images for care and treatment purposes, performed by BHP. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of failure to resolve the condition under treatment, injury or even death. I acknowledge that no warranties or guarantees have been made to me regarding the outcome of any examination or care. I consent to BHP taking digital images of me for identification and security purposes.
Telehealth/Telemedicine: BHP solely provides medical care through telehealth appointments. Telehealth/telemedicine involves the use of audio, video or other electronic communications to interact with me for the purpose of diagnosis, therapy, follow-up and/or education. A physical examination of me or if my child is the patient an examination of my child may take place and video, audio, and/or photo recordings may be taken. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I attest that I am located in the state of California and will be present in the state of California during all telehealth encounters with BHP. I understand that if I am not physically located in California I can not receive care at BHP. I consent to the use of telehealth/telemedicine with BHP.
Release of Medical Information: The State of California information Practices Act requires BHP to provide the following information to individuals who supply information about themselves. As a patient of BHP I will be asked to submit certain personal information such as my address and phone number, social security number, insurance information, medical history and treatment. The principal purpose of requesting this information is to ensure accurate identification, continuity of medical care and payment for such care. Federal and state law dictates that BHP is authorized to maintain this information. As required by BHP, furnishing all information requested is mandatory unless otherwise noted. I understand that failure to provide such information may affect my medical care and/or insurance benefits and coverage. BHP will obtain my written authorization to release information about my medical treatment except in those circumstances when BHP is permitted or required by law to release information. BHP may release a copy of my patient record to health care providers, health plans, government agencies and workers compensation carriers. I understand that if I am diagnosed with a reportable disease in California, BHP is required by law to report my diagnosis to the State Department of Health Services.
Financial Agreement: I understand and agree that even if I have insurance I may be financially responsible for some or all of my medical services. If I have a co-pay, co-insurance or cost-share or deductible I agree to pay the amount I owe to BHP. If I do not have insurance that covers the service I receive I agree to pay BHP for the professional and clinical services it provides. If this agreement is signed by my spouse, parent or financial guarantor, my spouse, parent or financial guarantor shall be jointly and individually liable with me for payment including all collection fees in addition to the other amounts due. Unpaid accounts referred to outside agencies for collection bear interest at the current legal rate.
Assignment of Benefits: I authorize and direct payment to BHP of any insurance benefits including unemployment compensation disability benefits otherwise payable to or on my behalf for BHP at a rate not to exceed BHP actual charges. I understand that I am financially responsible for changes not paid pursuant to this agreement. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to BHP by me.
Health Plans: BHP maintains a list of commercial health plans it has contracts with and is available by visiting BeachHousePediatrics.com. If BHP currently has a contract with my commercial health plan that covers my medical care at BHP I authorize BHP to submit a claim to the commercial health plan for healthcare services and items BHP provides. If BHP does not accept my insurance I acknowledge that I am responsible for paying the usual and customary charges at the time of care. I further acknowledge that it is my responsibility to determine if BHP accepts my insurance.
Self-Pay: If I do not have coverage from a third party source for the medical care BHP provides to me I agree to pay the total of BHP’s usual and customary charges at the time of care. The self-pay cost can be found on the BHP website BeachHousePediatrics.com.
Communication Methods: I understand that I will receive communication through automated emails, voicemails, written and/or electronic statements, text messages for appointments, billing and health-related purposes. I understand that these communications could result in charges to me by my mobile service provider and are not encrypted. I agree that BHP or its agents may use the wireless number(s) and/or residential phone lines that I have or will provide to send additional messages about my care and billing for such care.
Confirmations: I confirm that I have read the preceding information. I am the patient or legal guardian of the patient or am otherwise authorized by the patient to sign the above and accept the terms on his/her/their behalf. If I am not the patient I understand and agree that any references to "I", "my" or "myself" are deemed to include the patient.
Acknowledgement of Receipt of Privacy Practices: I have reviewed Beach House Pediatric, PC Notice of Privacy Practices. This notice provides information about how my protected health information may be used or disclosed. I may review the Notice of Privacy Practices any time at BeachHousePediatrics.com.
Notice of Privacy Practices
Beach House Pediatrics, PC is committed to protecting your medical, mental health and personal information. We are required by law to maintain the privacy of your health information, provide you with information about our privacy practices and legal duties and inform you of your rights. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your rights:
You can ask to see or receive an electronic or paper copy of your medical record and other health information we have about you. This request should be made in writing. We will provide a copy of your health information usually within 15 days of your request. We may change a reasonable cost-based fee.
You may request in writing to correct health information about you or your dependent child if you think it is incorrect or incomplete. You must be specific about why it is incorrect We may decline this request but will provide written notice of why this was declined within 60 days.
You may ask us to contact you in a specific way or send mail to a different address. This should be done in writing but we will try to accommodate a verbal request if it is reasonable.
You have the right to request a restriction or limitation on the Health Information we use or disclose about you for treatment, payment or health care operations. You also have the right to limit the health information we disclose about you to someone who is involved in your care or the payment of your care. This restriction should be requested in writing and include what information you want to limit and to whom you want the limits to apply. You should also include whether you want to limit our use, disclosure or both. We are not required to agree to your request and may decline this if it would affect your care.
If you pay for a service out of pocket in full you can ask us to not share that information for the purpose of payment or our operations with your health insurer unless a law requires us to share this information.
You may ask for a list of times we have shared your health information, with whom it has been shared and why for up to 6 years prior to the date you ask. We will include one accounting report per 12 month period without cost but will charge a reasonable fee for additional requests within the same 12 month period.
If you have given someone medical power of attorney or if someone is your legal guardian that person can exercise your rights and make choices about your health information. We will make sure that person has the authority to act before taking any action.
If you feel we have violated your rights you may complain to our owner at BeachHousePediatrics.com or you can file a complaint with the US Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.
You may ask to receive a copy of this notice any time even if you agreed to receive the notice electronically.
Our Uses and Disclosures:
We may use information about you to provide you with medical treatment and services. We can share it with other professionals who are treating you such as doctors, nurses or others involved in your care including those providing care to you in hospitals, nursing homes or medical staff in care facilities. We can use and share your health information to run our practice, improve your care and contact you when necessary. We may share your health information to support necessary business, legal, auditing, financial and clinical functions.
We can use and share your information to bill and get payment from health plans and other entities.
We are required or allowed to share your information in ways that contribute to the public good such as public health, preventing disease, reporting adverse effects of medications.
We may use or disclose health information in reporting suspected abuse or neglect, domestic violence, preventing a serious threat to anyone’s health or safety..
We can use or share your health information for workers compensation claims.
We may share your health information for law enforcement purposes. We can share health information about you in response to a court or administrative order or in response to a subpoena.
We can use or share your information for health research.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy laws.
Use and disclosure of health information that are not discussed in this notice or required by law will only be made with your written permission. If you provide us with permission to use your health information you can revoke this in writing at any time. Your written authorization will usually be required for most uses and disclosures of HIV test results, outpatient psychotherapy, involuntary commitment and alcohol and drug abuse treatment information.
We are required by law to maintain the privacy and security of your protected health information. We will contact you promptly should a breach of your privacy or security occur. We will not share your information other than as described here unless you inform us in writing that we can. You may revoke this permission at any time.
We reserve the right to change the privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for Health Information we already have about you as well as any information we receive in the future.