FINANCIAL POLICIES

FEES AND PAYMENTS:

All services are paid for by the patient prior to  initiating any service/product packages. You may pay via cash, check or credit card. We can accommodate HSA or FSA account payments in some limited situations.

INSURANCE: The practice currently accepts Blue Cross Blue Shield. Copay due at time of service per insurance card. If copay not specified or a percentage is listed a flat rate of $50 will be collected for services pending insurance review.

 There is a $30.00 fee for any check returned by the bank.

 All payments are due at the time of service. Upon request, the cost of services may be split between 2 payments due at time of service and within 30 days of the first appointment.

 Please know that we are here to help you if you have any questions.

MISSED APPOINTMENT FEE - Please provide 24-hour notice for appointment cancelations. There is a $50 charge for missed appointments without 24 hr. notice. This payment is expected before any further appointments can be scheduled.

PHONE CALLS -  Phone calls requiring 10 minutes or more of the provider's time will be charged as a minimum visit ($40/15 minutes).

DISCOUNTS - The practice offers discounts to active-duty military and veterans.

PAST DUE ACCOUNTS - If your account becomes past due, we will take necessary steps to collect this debt. At the time of your initial office visit, a copy of your credit card will be taken. If your account becomes past due over 60 days, that credit card will be charged. If the credit card declines or there are any other problems, your account will be referred to our collection agency. You will be charged for this service in addition to your current account balance. If payment is not received, your credit report will be blemished. If we have to refer the collection of the balance to a lawyer, you agree to pay all of the lawyer's fees which we incur, plus all court costs.

COPIES - The cost for copies of lab work, chart notes, imaging, and invoices will be 50 cents per page, EXCEPT if requested at the time of the visit. Lab work, chart notes, imaging, and invoices pertinent to the visit will be provided free of charge on the day of the visit. Most documents will also be available for you on the patient portal.

SPECIAL LETTERS, FORMS, and DOCUMENTS - Completing special insurance forms, workplace documentation, writing letters of medical necessity, etc. require significant provider time and will be charged an administrative fee of $25 per document/letter. Fees must be paid in advance. Some documentation may require extensive time / complexity and may justify a higher fee. If so, this fee will be disclosed to you prior to preparing the documents.

DISCLAIMER

Many supplements, vitamins, medical grade foods, nutritional powders, botanicals, and advanced regenerative remedies have not been evaluated by the US Food & Drug Administration (FDA) and these products are not intended to diagnose, treat, cure, or prevent any disease.

NO REFUNDS, CREDITS, OR EXCHANGES are allowed on any treatments. Once these items have been purchased, shipped to you, or left the office, they cannot be brought back under any circumstance.

PRIVACY POLICY / HIPPA COMPLIANCE

OUR LEGAL RESPONSIBILITIES

We are required by law to give you this notice. It provides you with how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information. 

We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information. 

You may request a copy of our notice any time. You may contact the practice at info@ilaintegrativehealth.com at any time to request a copy of this privacy policy.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION:

The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations, etc. but please be advised that not every use or disclosure in a particular category will be listed.

Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.

For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy, when a prescription is called in.

Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you by telephone, email, or text to remind you of your appointments.

If we have to share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.

We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.

Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.

Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure, and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional

information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.

Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so.

Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.

Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.

Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.

Worker's Compensation: We may disclose your protected health information to Worker's Compensation or similar programs.

Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.

Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements. 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.

Amendment: If you believe the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You will need to submit a written request as to

why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason why it should be amended. If we deny your request, we will provide you with a written explanation. We may deny your request if we believe the protected health information is accurate and complete.

Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” from the individual listed at the bottom of this policy. After your request has been approved, we will provide you with the dates of the disclosure, the name of the individual or entity we disclosed the

information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than allowed by the statute of limitations prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.

Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.

Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.

Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. 

Name of Contact Person:

Courtney Montgomery DNP, APRN-C Ila Integrative Health LLC info@ilaintegrativehealth.com  

PATIENT RIGHTS AND RESPONSIBILITIES

We are committed to serving you with compassion, care, and respect. As one of our valued clients, you are entitled to the following: 

You have the right:

To be treated with respect and dignity.

To know the name and professional status of the person(s) serving you. To privacy and confidentiality.

To receive accurate information about your health-related concerns.

To know the effectiveness and potential side-effects of all forms of treatment. To participate in choosing the form of treatment best suited to your skin.

To receive education and counseling about treatment. To review your medical record with your clinician.

To amend your records.

To receive any information about potential services or related services 

You have the responsibility:

To seek medical attention promptly, and to provide useful feedback. To be honest about your medical and social history.

To be honest about your lifestyle risks and exposures. To ask questions about anything you do not understand.

To follow health advice and instructions.

To report any significant changes in your health. To respect clinic policies.

To show up for appointments or cancel 48 hours in advance.