Lake Ray Hubbard Pediatrics, PA
David P. Granger, MD, F.A.A.P.
Vincent R. Iannelli, MD, F.A.A.P.
Susan M. Smart, MD, F.A.A.P.
Kristen D. Waw, MD, F.A.A.P.
Emily C. Thomason, DO,
Stacey M. Humphreys, CPNP
Acknowledgment of Receipt Of
Notice Of Privacy Practices
My signature below indicates that I have received a copy of the
“Notice of Privacy Practices” for Lake Ray Hubbard Pediatrics, PA.
__________________________________________________________________
Parent Name (please print)
Account Number(s)
__________________________________________________________________
Parent Signature
Date
For Office Use Only
We attempted to obtain written acknowledgment of receipt of our Notice Of Privacy Practices, but
acknowledgment could not be obtained because:
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Individual refused to sign.
Communications barriers prohibited obtaining the acknowledgment.
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LAKE RAY HUBBARD PEDIATRICS, PA
9100 LAKEVIEW PARKWAY
ROWLETT, TX 75088
972-412-3034
This is our office policy, please read carefully and sign at the bottom.
APPOINTMENTS:
Patients are seen by appointment only. All children will be scheduled as appointments become
available. We make every effort to stay on schedule. Please help us keep on schedule by arriving for
your appointment at least 10 to 15 minutes early. Patients who are more than 15 minutes late may be
asked to reschedule their appointments so that we do not keep our other scheduled patients waiting.
Please give 24 hours notice prior to cancelling your appointments. There may be a charge for
appointments cancelled less than 24 hours in advance. Repeated missed appointments may result in your
discharge from this practice.
AFTER OFFICE HOURS:
We are available 24 hours daily for emergencies and serious illnesses. Please limit after hours calls to
serious illness and emergencies. You can reach us by dialing the office telephone number. If it is after
hours, our answering machine will instruct you to call our answering service. We will return your call
within 10-15 minutes unless we are tied up with an emergency. If your call is not returned within 30
minutes, please call back.
In case of a life-threatening emergencies where 15-20 minutes is too long to wait, call 911 or go to
the nearest Emergency Room. In most cases that will be Lake Pointe Medical Center in Rowlett. If you
subscribe to “Caller ID” and “Anonymous Call Rejection” please be advised that most phones utilized by
our doctors and staff have caller ID blocking and will reflect “anonymous” or “private” when your phone
calls are returned. Be aware that this could cause a problem if the doctor or staff is trying to reach you.
GENERAL POLICIES:
Antibiotics are not prescribed or refilled without a physician assessment.
Referrals and authorizations are not given without a physician assessment.
Requests for medication refills should be called in during regular office hours. Please keep track
of your supply of medication and request refills before running out.
48 hour (two working days) notice is required to refill triplicate prescriptions. Note that you have
21 days to fill these prescriptions. There will be a charge for having to re-write triplicate
prescriptions.
MEDICAL RECORDS:
We need written authorization prior to transferring records.
There is a fee for copying the chart when records are released to the family or another physician.
We require 10 working days to process medical records requests.
We do not fax medical records. They will be sent by mail.
INSURANCE PATIENTS:
A copy of your insurance card will be required at every visit. Payment of applicable deductibles
and co-payments are due at the time service is rendered.
It is your responsibility to provide us with all the necessary insurance information each time your
insurance changes. Insurance companies have established filing deadlines so we need your
current insurance information on file at all times.
We only file primary insurance. Secondary must be filed by the parent.
Insurance Denials: It is your responsibility to appeal denials to your insurance company. When your
claim is denied the insurance balance becomes your personal balance. Failure to pay this balance or
quickly rectify the situation with your insurance company will eventually lead to collection procedures.
SELF PAY PATIENTS:
Payment is due at the time of service. Payment plans may be arranged if necessary.
DELINQUENT ACCOUNTS:
You must immediately provide us with any change of address or phone number.
Your insurance coverage is an agreement between you and your insurance company. Payment of
your account is your responsibility.
Personal balances are due when billed and become past due at 60 days.
Billing is automated and accounts over 120 days past due are automatically turned over to an
agency for collection.
Failure to receive bills from our office due to incorrect address information or refusal to pick up
certified letters will eventually lead to the collection process.
Accounts turned over to collection are permanently closed. We will no longer be available for
further medical care.
DIVORCED OR SEPARATED PARENTS:
Full payment is the responsibility of the parent who brings the child into the office for treatment.
This is regardless of the terms outlined in a divorce decree. This is a matter between the divorced
parents and the courts. We will not be placed in the middle.
____________________________________________________________________
Parent’s Signature
Date
NOTICE OF PRIVACY PRACTICES
Lake Ray Hubbard Pediatrics, PA
(Dr. David P. Granger, Dr. Vincent R. Iannelli,
Dr. Kristen D. Waw, Dr. Susan M. Smart, Dr. Emily C. Thomason)
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR FAMILY
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996,
also know as HIPAA, we are required by law to maintain the privacy of your Protected Health Information (PHI) and to provide
you with this Notice of our privacy practices, our legal duties, and your rights concerning your health information.
Our office is required to abide by the terms of this Notice of Privacy Practices. As time passes our privacy practices and the law
related to them may change which may require a change to this notice. The revised notice will be posted in our office. For more
information about our privacy practices, or for additional copies of the notice, please contact us using the information listed at the
end of the notice.
Protected Health Information (PHI) includes, but is not limited to, medical records, lab reports, referrals, radiology/imaging,
specialist consultations, immunization records, current demographics, insurance information, telephone conversations and/or
messages.
Permissible Uses And Disclosures Of PHI Without Your Written Authorization
We will use and disclose Protected Health Information about your family for treatment, payment, and healthcare operations. For
example:
Treatment: To maintain high quality healthcare, it will be necessary to share protected health information with all members of
your treatment team. This can include employees in this office as well as other health care providers. We may also use or
disclose your health information to provide you with appointment reminders such as voice mail message, postcards and or letters.
Payment: Necessary information will be shared with appropriate payor sources and their representatives for payment purposes
including, but not limited to eligibility, benefit determination, claim processing and utilization review. It will also be necessary
for our billing personnel to have access to PHI information to carry out their billing and collection efforts.
Healthcare Operations: Necessary information will be shared for the continuing operations of this office. Some examples
include, but are not limited to peer review, accreditation, and compliance with all federal and state laws.
We may also disclose PHI to our business associates for the treatment, payment of health care operations, or to other health care
providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain
health care operations, such as quality assessment and improvement activities.
A child's PHI will be provided to the child's family members other than the parents, such as grandparents, uncles, aunts, brother
and sisters unless a specific request not to do so is on file from the parents.
Specific Authorization Required For Other Uses And Disclosures Of PHI
Other uses and disclosures of your protected health information will only be made with your written authorization. This
authorization will only allow the use or disclosure of the specific information detailed on the authorization form you provide.
Any specific authorizations you request will remain in effect till you revoke the authorization in writing. Some examples include
but are not limited to; marketing activities, the use or disclosure of psychotherapy records in our possession, transferring of your
child's medical records in our possession to other doctors and in some instances for research purposes. Two exceptions to the
written authorization requirement will be for shot records and school related documents which will be provided based on verbal
requests by the parent or guardian. Parent identity verification may be required for each request .
Other Uses And Disclosures Of PHI May Be Made Without Your Authorization
The following are situations where this office may use or disclose your PHI without your consent or authorization:
As required by law, court orders, a legal process, or government agencies.
For matters of public health for the purpose of controlling disease as dictated by law.
Disclosures to government oversight agencies for the purpose of health and privacy audits or investigations.
Disclosures may be made to public health authorities in situations of suspected abuse or neglect.
Disclosures to Institutional Review Boards of your de-identified information for the purpose of medical research.
Patient Rights effective April 14, 2003
In general you will have the right to look at or receive a copy of your protected health information. Requests for this information
must be in writing and detail the information your are requesting. Some exceptions include but are not limited to: psychotherapy
notes, information compiled for use in a civil, criminal, or administrative proceedings. There will be an administrative charge for
expenses such as making copies and staff time. Please allow 48 hours for copies to be made available.
You have the right to request a restriction of the disclosure of your protected health information for treatment, payment, or
operations. This office is not required to agree to the request, but will do so at our discretion based on medical and business
need. The request may not apply in some emergency situations. These requests must be submitted in writing.
You have the right to request to receive confidential communications from us by alternative means or to an alternative location.
We will make every effort to honor reasonable requests. These requests must be submitted in writing.
You have the right to request an accounting of the disclosures made of your protected health information by this office (after
April 14, 2003). This only applies to disclosures made for purposes other than treatment, payment, and healthcare operations.
Only one request a year will be allowed. There may be a charge for this preparation of this information. These requests must be
submitted in writing.
You have the right to request that we amend your protected health information in your medical records. If you desire to amend
your records, please obtain an amendment request form from the Privacy Officer and submit the completed form to the Privacy
Officer. We will comply with your request unless we believe that the information that would be amended is accurate and
complete and or other special circumstances apply.
You may submit a written complaint to the Director, Office of Civil Rights of the US Department of Health and Human Services
if you (1) are concerned that we may have violated your privacy rights, (2) disagree with a decision we made about access to
your health information, (3) disagree with a response we made to a request to amend or restrict the use or disclosure of your
heath information or to have us communicate with you by alternative means or at alternative locations. We would ask that you
first contact us regarding your problem and allow us the opportunity to resolve your issue. At no time will there be any
retaliation against a family for filing a complaint.
Questions and Concerns
If you need additional information regarding our privacy practices, or have questions or concerns, please contact our Privacy
Officer at 972-412-3034 Ext. 120. If you need to contact us by mail please send your correspondence to:
Lake Ray Hubbard Pediatrics
Attn.: Privacy Officer
9100 Lakeview Parkway
Rowlett, TX, 75088
Lake Ray Hubbard Pediatrics, PA
Request for release of medical records:
Physician Name: _______________________________________
Address: ______________________________________________
City:
State:
Zip: ________
I hereby request that the medical records for:
Patient’s Name:
DOB: _________
Patient’s Name:
DOB: _________
Patient’s Name:
DOB: _________
Patient’s Name:
DOB: _________
Be released to:
Mail to:
_____ David P. Granger, M.D.
_____ Vincent R. Iannelli, M.D.
_____ Susan M. Smart, M.D.
_____ Kristen D. Waw, M.D.
_____ Emily C. Thomason, D.O.
_____ Stacey M. Humphreys, CPNP
Lake Ray Hubbard Pediatrics, PA
9100 Lakeview Parkway
Rowlett, Texas 75088
972 412-3034 Office
972 412-3695 Fax
Parent/Legal Guardian Signature: ____________________________
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Date: ___________________
NEW INSURANCE INTAKE SHEET
DATE: ________________________
CANCELLATION DATE OF OLD POLICY: _________________________
EFFECTIVE DATE OF NEW POLICY: _________________________
SUBSCRIBER NAME: ________________________________
SUBSCRIBER DOB: ________________________
SUBSCRIBER SSN: __________________________
SUBSCRIBER EMPLOYER: ________________________________
ALL CHILDREN ON POLICY: ____________________________________
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