Prescription Medication Refill Policy:
- Prescription refills are processed Monday-Friday (8:00 am to 4:30 pm).
- Contact your pharmacy for all refills needed. Controlled substances will need to be filled by notifying the office, via the patient portal.
- Please allow 48 hours to process your request. Contact your pharmacy after 48 hours to confirm that refill has been processed.
- New prescriptions and/or new problems or symptoms require a clinic appointment.
Referrals:
- Please give us at least 48 hours to complete any referrals to go see specialists. No referrals will be processed on the same day of the appointment due to insurance requiring proper notice to process referrals.
Patient Information and Insurance Cards:
- Your personal information and insurance card are an important part of your medical record. It is your responsibility to make sure that you update this information at each visit to keep your record current and up to date. While this may seem inconvenient, it is necessary to insure claims are processed correctly.
Late Policy:
- Every effort is made to keep our physicians’ schedules on time; therefore, if you are more than 15 minutes late we cannot guarantee that you will be seen immediately, but we will do our best to work you in to the schedule as time permits. If all the physicians’ schedules are full you will be asked to reschedule your appointment to a later date.
Missed/Cancelled Appointments or Procedures:
- Every effort is made to accommodate our patient’s request for appointments or procedures; therefore, it is important that you make every effort to keep you scheduled appointments. No shows and appointments cancelled within 24 hours will be subject to a fee of $50.00. Please be advised that multiple missed appointments may result in dismissal from our practice.
Forms:
- This is a non-insurance covered service which requires time from administrative and nursing staff as well as the doctors. A fee of $30.00 will be charged for the completion of forms and/or for the writing of letters. The fee is due at the time of the request. Please allow 7-10 business days to complete your request.
Payment for Services for Patients with Insurance:
- According to your health insurance plan you are responsible for paying your co-payment at the time of service. Co-pays that are not paid at the time of service will be billed with an additional $5.00 fee. This fee is necessary to cover administrative and supply costs associated with billing co-pays.
Non-Contracted Insurance Plans:
- If we are not participating with your insurance, such as the Kaiser Health policy, payment is due at the time of the visit. We do not submit claims to insurance plans we are not contracted with.
Payment for Services for Patients without Insurance:
- You will be responsible for payment by cash or credit card on the day of service. If you are not able to pay in full at the time of service, you will need to contact Our billing office prior to your appointment, payment plans may be available. Our practice does offer discounts when the payment in full is received at the time of service. Failure to pay for services may result in dismissal from our practice and your account be sent to an outside collection agency.
Balances and Deductibles:
- It is our responsibility, as detailed by the terms of our contracts with the health insurance companies that we participate with, to bill you for any portion of your treatment that your health insurance carrier assigns as your responsibility. It is your responsibility to pay this portion of your bill. If you do not remit full payment (or call us to set up a payment plan) on any such bills within a reasonable period and with reasonable notice, your account may be sent to collections and subject to collection fees. If you are having Difficulty meeting medical bills, please let us know and we will be happy to help you by setting up a payment plan. There will be a $5 convenience fee added each month for accounts on payment plans, subject to change. We encourage you to contact our billing office via phone at (703) 441-1905 or via email at info@serenitemedspa.com, with any questions or concerns. Failure to address your financial obligations with us may result in dismissal from our practice.
Past Due Balances:
- If your account is more than 60 days past due and you have not set up any payment plan with the office it will be sent to an outside collection agency and they will charge an additional collection fee.
Inclement Weather:
- We do our best to ensure that we are here for patient care. However, if we feel the roads are not safe due to weather conditions, we will make the appropriate decisions necessary to either close our office, open late or cancel evening clinic. We will do the best that we can to contact patients, if information is available to our staff.
Privacy Practice:
- To obtain a copy of our Privacy Practice, please contact our Office Manager at 703-441-1905.
Returned Checks:
- There is a fee of $50.00 for any check returned by your bank.
I have read, understand, accept and agree to comply with all of the above policies. I authorize treatment of and agree to pay all fees and charges for such treatment. I agree to pay all charges promptly upon presentment thereof. I hereby authorize the release of any pertinent information to my insurance company. I acknowledge that payments will not be delayed or withheld due to insurance coverage or pending claims. I acknowledge that all proceeds of insurance are assigned to Serenite Medical & Spa where applicable and Serenite Medical & Spa assumes no responsibility for the collection of any proceeds of insurance.
PATIENT SIGNATURE: _________________________________________ DATE: _____________________
Signature is required, stating that you have received a copy of our policy and procedures.
PRINTED NAME: ___________________________________________
Signature is required, stating that you have received a copy of our policy and procedures.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU CAN GET ACCESS TO THIS INFORMATION, YOUR RIGHTS CONCERNING YOUR HEALTH INFORMATION AND OUR RESPONSIBILITIES TO PROTECT YOUR HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.
State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We are required to abide by the terms of this Notice of Privacy Practices. This Notice will take effect on September 1, 2013 and will remain in effect until it is amended or replaced by us.
We reserve the right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.
You may request a copy of our Privacy Notice at any time by contacting us at any time. Information on contacting us can be found at the end of this Notice.
We will keep your health information confidential, using it only for the following purposes:
Treatment:
- While we are providing you with health care services, we may share your protected health information (PHI) including electronic protected health information (ePHI) with other health care providers, business associates and their subcontractors or individuals who are involved in your treatment, billing, administrative support or data analysis. These business associates and subcontractors through signed contracts are required by Federal law to protect your health information. We have established “minimum necessary” or “need to know” standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
Payment:
- We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations, collections or other third parties that may be responsible for such costs, such as family members.
Disclosure:
- We may disclose and/or share protected health information (PHI) including electronic disclosure with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.
- As of March 26, 2013, immunization records for students may be released without an authorization (as long as the PHI disclosed is limited to proof of immunization).
- If an individual is deceased you may disclose PHI to a family member or individual involved in care or payment prior to death.
- Psychotherapy notes will not be used or disclosed without your written authorization.
- Genetic Information Nondiscrimination Act (GINA) prohibits health plans from using or disclosing genetic information for underwriting purposes.
- Uses and disclosures not described in this notice will be made only with your signed authorization.
Right to an Accounting of Disclosures:
- You have the right to request an “accounting of disclosures” of your protected information if the disclosure was made for purposes other than providing services, payment, and or business operations.
- In light of the increasing use of Electronic Medical Record technology (EMR), the HITECH Act allows you the right to request a copy of your health information in electronic form if we store your information electronically. Disclosures can be made available for a period of 6 years prior to your request and for electronic health information 3 years prior to the date on which the accounting is requested. If for some reason we aren’t capable of an electronic format, a readable hardcopy will be provided.
- To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Lists, if requested, will be $0.50 for each page and the staff time charged will be $0 per hour including the time required to locate and copy your health information. Please contact our Privacy Officer for an explanation of our fee structure.
Right to Request Restriction of PHI:
- If you pay in full out of pocket for your treatment, you can instruct us not to share information about your treatment with your health plan; if the request is not required by law. Effective March 26, 2013, The Omnibus Rule restricts provider’s refusal of an individual’s request not to disclose PHI.
Non-routine Disclosures:
- You have the right to receive a list of non-routine disclosures we have made of your health care information. You can request non-routine disclosures going back 6 years starting on April 14, 2003.
Emergencies:
- We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.
Healthcare Operations:
- We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, insurance operations, health care clearinghouses and individuals performing similar activities.
Required by Law:
- We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.
National Security:
- The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.
Abuse or Neglect:
- We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.
Public Health Responsibilities:
- We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing Health-Related Services:
- We will not use your health information for marketing purposes unless we have your written authorization to do so. Effective March 26, 2013, we are required to obtain an authorization for marketing purposes if communication about a product or service is provided and we receive financial remuneration (getting paid in exchange for making the communication). No authorization is required if communication is made face-to-face or for promotional gifts.
Fundraising:
- We may use certain information (name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money and you will have the right to opt out of receiving such communications with each solicitation. Effective March 26, 2013, PHI that requires a written patient authorization prior to fundraising communication include: diagnosis, nature of services and treatment. If you have elected to opt out we are prohibited from making fundraising communication under the HIPAA Privacy Rule.
Sale of PHI:
- We are prohibited to disclose PHI without an authorization if it constitutes remuneration (getting paid in exchange for the PHI). “Sale of PHI” does not include disclosures for public health, certain research purposes, treatment and payment, and for any other purpose permitted by the Privacy Rule, where the only remuneration received is “a reasonable cost-based fee” to cover the cost to prepare and transmit the PHI for such purpose or a fee otherwise expressly permitted by law. Corporate transactions (i.e., sale, transfer, merger, consolidation) are also excluded from the definition of “sale”.
Appointment Reminders:
- We may use your health records to remind you of recommended services, treatment or scheduled appointments.
Access:
- Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) We will provide access to health information in a form / format requested by you. There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the request form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $0.50 for each page and the staff time charged will be $0 per hour including the time required to copy your health information. If you want the copies mailed to you, postage will also be charged. Access to your health information in electronic form if (readily producible) may be obtained with your request. If for some reason we aren’t capable of an electronic format, a readable hardcopy will be provided. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for an explanation of our fee structure.
Amendment:
- You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Breach Notification Requirements:
- It is presumed that any acquisition, access, use or disclosure of PHI not permitted under HIPAA regulations is a breach. We are required to complete a risk assessment, and if necessary, inform HHS and take any other steps required by law. You will be notified of the situation and any steps you should take to protect yourself against harm due to the breach.
QUESTIONS AND COMPLAINTS
You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
HOW TO CONTACT US:
Serenite Medical & Spa Inc 3771 Fetler Park Drive Dumfries, VA 22026 Phone: 703-441-1905 Fax: 703-441-1905 Email: info@serenitemedicalandspa.com
Office Procedures Protocols
Sérénité Medical & Spa 3771 Fettler Park Drive Dumfries, Virginia. 22025 Tel: (703) 441 1905
Date: 08/14/2023 Effective immediately
Patients that require a physical examination or any breast, rectal or vaginal examination need to have a chaperon during the examination if the patient refuses to have a chaperon. The Doctor or MA should have the patient sign a waiver refusing the chaperon. The doctor or medical assistance needs to provide the patient with a drape for their privacy.
Patient that needs any refills for any controlled mediation or sleep aid, for example Adderall, Ambien, gabapentin etc. needs to have a consultation every 30 days.
If a patient has any complaint not related to their health, the complaint should be written by the person receiving the complaint or the office manager. The complaint needs to be documented under a complaint folder.
Drug Testing for Suboxone Program
Drug tests should be performed as soon as the specimen is collected. Patients need to be instructed to leave all their personal items in the room while they collect their specimens. If the sample doesn’t meet the criteria qualifications, which are warm temp 90-100F and at least 40ml, the specimen can’t be accepted.
The collection cup provided to the patient should be sealed. If a patient fails a drug test, the patient will receive a warning and needs to have a more frequent drug screen for at least 3 months. If a patient fails a second drug screen the patient will be discharged from the program.
Suboxone Count:
- Patients will be instructed to bring their suboxone at the time of visit to do a count this could be done randomly. Patient will be advised to get counseling.