Patient Forms & Policies

Please be aware that effective immediately ALL prescription refills and non-emergent medical questions will be handled through our Patient Portal.

You can access our Patient Portal from our website by clicking here.

Due to the ever changing rules and regulations of HIPAA that we are required to adhere to, the Patient Portal gives you a more secure method of contact.

Thank you for your cooperation!

We try to fill prescription requests as soon as possible but please allow 48 hours for requests to be filled. Our providers work on prescription requests when they have time in their schedule which is usually at the end of the day. For this reason, we cannot fill prescriptions for walk-ins while they wait.

You may contact us in one of 2 ways for a prescription refill.

• Through the Patient Portal is our preferred method of contact.
• CALL us at 518-563-3260 and select Option #3 for the nursing line.

For all prescription refill requests, we will need to have the following:

1. Your name and date of birth.
2. The prescription that needs to be refilled including the dosage.
3. A phone number to reach you during the day with questions.

If your insurance requires a 90 day supply, a generic equivalent or a prior authorization, please let us know at the time of the request.

We only call prescriptions in on an urgent basis. In most circumstances, we are required to electronically send in prescriptions.

Again, it is our goal to provide you with timely prescription refills. Most will be filled within 24 hours. We thank you for your patience and understanding.

WITH MY CONSENT, ASSOCIATES IN OBSTETRICS & GYNECOLOGY, P.C. may use and disclose PROTECTED HEALTH INFORMATION (PHI) about me to carry out TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS (TPO). PLEASE REFER TO ASSOCIATES IN OBSTETRICS & GYNECOLOGY, P.C.'S NOTICE OF PRIVACY PRACTICES FOR A MORE COMPLETE DESCRIPTION OF SUCH USES AND DISCLOSURES.

I have the right to review the Notice of Privacy Practices prior to signing this consent. ASSOCIATES IN OBSTETRICS&. GYNECOLOGY, P.C. RESERVES THE RIGHT TO REVISE ITS NOTICE OF PRIVACY PRACTICES AT ANY TIME, A REVISED NOTICE OF PRIVACY PRACTICES MAY BE OBTAINED BY FORWARDING A WRITTEN REQUEST TO ASSOCIATES IN OBSTETRICS & GYNECOLOGY, P.C. PRIVACY OFFICf:R AT 25 DEGRANDPRE WAY, PLATTSBURGH, NY 12901.

WITH MY CONSENT, ASSOCIATES IN OBSTETRICS &. GYNECOLOGY, P,C. may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice In carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, Including laboratory results among others.

WITH MY CONSENT, ASSOCIATES IN OBSTETRICS &.GYNECOLOGY, P,C. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

WITH MY CONSENT, ASSOCIATES IN OBSTETRICS&. GYNECOLOGY, P.C. may e-mail to my home or other designated location any Items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that ASSOCIATES IN OBSTETRICS & GYNECOLOGY, P.C. restrict how it uses or disclosed my PHI to carry out TPO. However, the practice Is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

All charges are due at the time of service. If surgery Is indicated the patient Is responsible for furnishing insurance claim forms to this office prior to surgery. All professional services rendered are charged to the patient. Necessary forms will be completed to expedite Insurance carrier payments. Toe patient is responsible for all fees regardless or Insurance coverage. It Is customary to pay for services when rendered unless other arrangements have been made in advance with the billing manager.

We are working to keep medical costs down. You can help a great deal by eliminating billing costs. Please understand that payment of your bill is considered part of your treatment. The following is a summary of your payment policy.

• Insurance cards need to be presented at each visit so that we can make sure that we have the correct insurance information.
• We need to have accurate and complete personal information, if anything changes, please let us know as soon as possible.
• All applicable co-pays, personal balances, both current and prior are due at time of service unless prior arrangements have been made with our billing department at 518-563-3275.
• We accept cash, local checks, debit cards, Mastercard/Visa, Discover Card, and American Express.
• If we do not participate with your insurance company or you do not have insurance, payment is expected at time of service unless other arrangements have been made with our billing department. We will submit the bill to your insurance company for you even though we do not participate with them and they will reimburse you directly.
• We accept assignment of benefits from all insurance companies with which we participate. But in all cases we require the guarantor (the person who is financially responsible) is liable for all balances not covered by insurance. It is your responsibility to understand and comply with any predetermination of benefits or referral requirements. Please be aware that some of the services provided may be "non­covered" services or may not be considered medically necessary under the Medicare program and other medical insurance companies.
• A liability action against someone (auto-accident, work injury, etc.) is not a reason for delaying payment of your bill.
• A billing statement covering medical services will be mailed to your approximately every 30 days. If a payment has not been received in 30 days, a $5.00 monthly charge will be added to your account.
• If we haven't received payment from your insurance company within 45 days of date of service, you will be expected to pay the balance in full.
• We have a $30.00 fee for returned checks.
• There is a no show fee of $25.00 if you do not call 24 hours prior to your appointment to cancel.
• If you have more than one insurance, we will bill your secondary insurance after we have received reimbursement from your primary insurance.
• Overpayments will be reimbursed upon written request to the responsible party within 30 days.‍
• We have a $10.00 fee for all prescriptions requested that need to be called in by an On-Call provider when the office is not open.

• Adhere to the standards set forward in the Notice of Privacy Practices
• Collect, use, and disclose PHI only in conformance with state and deferral laws and current patient covenants and/or authorizations, as appropriate. Our practice and its providers and staff will not use or disclose PHI for uses outside of practice's TPO, such as marketing, employment, life insurance applications, etc. without an authorization from the patient.
• Use and disclose PHI to remind patients of their appointments only within their consent
• Recognize that PHI collected about patients must be accurate, timely, complete, and available when needed. Our practice, its providers and staff will implement reasonable measures to protect the integrity of all PHI Maintained about patients.
• Recognize that patients have a right to privacy. Our practice and its providers and staff respect the patient's individual dignity at all times. Our practices and its providers and staff will respect patients privacy to the extent consistent with providing the highest quality medical care possible and with the efficient administration of the facility.
  
  Act as responsible information stewards and treat all PHI as sensitive and confidential. Consequently, our practice, its providers and staff will:
  ‍
  - Treat all PHI data as confidential in accordance with professional ethics, accreditation standards, and legal requirements.
  ‍
  - Not disclose PHI data unless the patient (or his or her authorized representative) has properly consented to or authorized the release or law otherwise authorizes the release.
• Recognize that, although our practice "owns" the medical record, the patient has a right to inspect and obtain a copy of his/her PHI. In addition, patients have a right to request an amendment to his/her medical a record if he/she believes his/her information ls inaccurate or incomplete.
  ‍
  - Permit patient's access to their medical records when their written requests are approved by our practice. If we deny their request, then we must inform the patients that they may request a review of denial. In such cases, we will have an on-site healthcare professional review the patient's appeals.
  
  - Provide patients an opportunity to request the correction of inaccurate or incomplete PHI in their medical records in accordance with the law and professional standards.
• All providers and staff of our practice will maintain a list of all disclosures of PHI for purposes other than TPO for each patient. We will provide this list to patients upon request, so long as their request is in writing.
• All providers and staff of our practice will adhere to any restrictions concerning the use or disclosure of PHI that patients have requested and have been approved by our practice.
• All providers and staff of our practice must adhere to this policy. Our practice will not tolerate any violations of this policy. Violation of this policy is grounds for disciplinary action, up to and including termination of employment and criminal or professional sanctions in accordance with our practice's personnel rules and regulations.

Our Practice may change this privacy policy in the future. Any changes will be effective upon the release of a revised privacy policy and will be made available to patients upon request.

We are working to keep medical costs down. You can help a great deal by eliminating billing costs. Please understand that payment of your bill is considered part of your treatment. The following is a summary of your payment policy.

• Insurance cards need to be presented at each visit so that we can make sure that we have the correct insurance information.
• We need to have accurate and complete personal information, if anything changes, please let us know as soon as possible.
• All applicable co-pays, personal balances, both current and prior are due at time of service unless prior arrangements have been made with our billing department at 518-563-3275.
• We accept cash, local checks, debit cards, Mastercard/Visa, Discover Card, and American Express.
• If we do not participate with your insurance company or you do not have insurance, payment is expected at time of service unless other arrangements have been made with our billing department. We will submit the bill to your insurance company for you even though we do not participate with them and they will reimburse you directly.
• We accept assignment of benefits from all insurance companies with which we participate. But in all cases we require the guarantor (the person who is financially responsible) is liable for all balances not covered by insurance. It is your responsibility to understand and comply with any predetermination of benefits or referral requirements. Please be aware that some of the services provided may be "non­covered" services or may not be considered medically necessary under the Medicare program and other medical insurance companies.
• A liability action against someone (auto-accident, work injury, etc.) is not a reason for delaying payment of your bill.
• A billing statement covering medical services will be mailed to your approximately every 30 days. If a payment has not been received in 30 days, a $5.00 monthly charge will be added to your account.
• If we haven't received payment from your insurance company within 45 days of date of service, you will be expected to pay the balance in full.
• We have a $30.00 fee for returned checks.
• There is a no show fee of $25.00 if you do not call 24 hours prior to your appointment to cancel.
• If you have more than one insurance, we will bill your secondary insurance after we have received reimbursement from your primary insurance.
• Overpayments will be reimbursed upon written request to the responsible party within 30 days.‍
• We have a $10.00 fee for all prescriptions requested that need to be called in by an On-Call provider when the office is not open.