Anchor Medical Associates may provide care to patients with the following insurance plans:

• Aetna

• Beacon Mutual

• Benesight

• Blue Chip

• Blue Cross Blue Shield – all states

• CIGNA

• Definity Health

• First Health

• Great West

• Harvard Pilgrim Health Care

• Health Care Value Management

• Health Net of NE

• Healthmate Coast to Coast

• Mashantucket Pequot Tribal Nation

• Mass Medicaid (in some offices)

• Medicare B

• Multiplan

• Neighborhood Health Plan of RI

• Out-Of-State Blue Cross and Blue Shield

• Oxford Health

• Private Health Care Systems

• RI Medicaid

• RI Medicare

• TriCare

• Tufts Health Care

• Tufts Public Health Care   

• UniCare

• UnitedHealthcare

• US Family Health Plan

• Other small business Insurances

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THE FOLLOWING DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your IIHI

• Your privacy rights in regard to your IIHI

• Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Joyce Caraman

Anchor Medical Associates

One Commerce Street

Lincoln RI 02865

401-793-8392

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS

The following categories describe the different ways in which we may use and disclose your IIHI.

1. Treatment

   Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors, nurses, physician’s assistants, nurse practitioners, and medical assistants – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents.

2. Payment

   Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items.

3. Health Care Operations

   Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

4. Appointment Reminders

   Our practice may use and disclose your IIHI to contact you and remind you of an appointment. This reminder may be in the form of a “closed” post card or message left on an answering machine or voice mail at a telephone number you provide to us.

5. Treatment Options

   Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.

6. Communication

   Our practice may use and disclose your IIHI to communicate with you regarding health care treatment, payment or operations. This includes:

   • Use of your first and last name in our waiting areas

   • Use of the telephone numbers you provide us for telephone calls to you at your home, work, or cellular telephone.

   • Use of electronic mail, if you contact your provider by electronic mail, and you and your provider are both willing to exchange IIHI via this method of communication.

7. Health-Related Benefits and Services

   Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.

8. Release of Information to Family/Friends

   Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take his/her child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

9. Disclosures Required By Law

   Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

Public Health Risks

Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths

Reporting child abuse or neglect

Preventing or controlling disease, injury or disability

Notifying a person regarding potential exposure to a communicable disease

Notifying a person regarding a potential risk for spreading or contracting a disease or condition

Reporting reactions to drugs or problems with products or devices

Notifying individuals if a product or device they may be using has been recalled

Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health Oversight Activities

Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and Similar Proceedings

Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, (subject to certain conditions required by law) but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement

We may release IIHI if asked to do so by a law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

Concerning a death we believe has resulted from criminal conduct

Regarding criminal conduct at our offices

In response to a warrant, summons, court order, subpoena or similar legal process

To identify/locate a suspect, material witness, fugitive or missing person

In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

Deceased Patients

Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death.

Organ and Tissue Donation

Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

Research

Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the oral or written agreement of a researcher that (i) the information being sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being used only for the research and (iii) the researcher will not remove any of your IIHI from our practice; or (c) the IIHI sought by the researcher only relates to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access to the IIHI of the decedents.

Serious Threats to Health or Safety

Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military

Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security

Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates

Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers’ Compensation

Our practice may release your IIHI for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR IIHI

You have the following rights regarding the IIHI that we maintain about you:

Confidential Communications

You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting Restrictions

You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865. Your request must describe in a clear and concise fashion:

(a) The information you wish restricted;

(b) Whether you are requesting to limit our practice’s use, disclosure or both; and

(c) To whom you want the limits to apply.

Inspection and Copies

You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865 in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Amendment

You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Accounting of Disclosures

All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a Paper Copy of This Notice

You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865 – 401-793-8392.

Right to File a Complaint

We would appreciate your advising us first of any complaints so that we may address your concerns promptly. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, all complaints must be submitted in writing to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865. You will not be penalized for filing a complaint.

Right to Provide an Authorization for Other Uses and Disclosures

Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact to Joyce Caraman, Anchor Medical Associates, One Commerce Street, Lincoln RI 02865 – 401-793-8392

Anchor Medical Associates is recognized as a Patient Centered Medical Home (PCMH) practice by the National Committee for Quality Assurance (NCQA), an organization dedicated to enhancing health care quality and safety. At a PCMH practice, patients receive quality care through a direct and long-term relationship with their chosen provider and health care team. Everyone at Anchor Medical Associates, both providers and staff, play a role in creating a PCMH practice that supports whole-person care.

Part of our obligation as a PCMH practice is to inform you of the following patient rights and responsibilities.

YOUR RIGHTS AS A PATIENT

You have the right to receive information about Anchor Medical Associates, its services, and its providers.

You have the right to be treated with dignity and respect and acknowledged as an individual with unique health care needs.

You have the right to respectful personal attention without regard to your race, national origin, gender, age, sexual orientation, language preference, religious affiliation, or pre-existing conditions.

You have the right to receive an understandable explanation of your health condition or status.

You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

You have the right to actively participate with your providers in decision-making regarding your health care.

You have the right to seek second opinions and we encourage you to discuss this with your provider.

You have the right to consent to or refuse any care or treatment.

You have the right to privacy of all records and communications to the extent required by law. Anchor Medical Associates providers and staff follow a strict confidentiality policy regarding all patient information.

You have the right to express any concerns you may have about Anchor Medical Associates, or the care provided by its providers or staff.

You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

YOUR RESPONSIBILITIES AS A PATIENT

You agree to choose a Primary Care Provider (PCP) who will direct your care, when coming to Anchor Medical Associates for primary care services.

You agree to meet with other members of your care team as the services they provide are vital to providing you with high quality, comprehensive care.

You agree to treat Anchor Medical Associates’ providers and staff with courtesy and respect.

You agree to be honest about your medical, dental, sexual, and mental health history.

You agree to disclose a complete health history and all current medications to your providers.

You agree to ask questions until you understand what you need to know about your health care.

You agree to follow health advice and medical instructions and express any concerns about your ability to follow the proposed plan of care.

You agree to report any changes in your health condition to your medical providers.

You agree to provide feedback about your service needs and expectations.

You agree to comply with our practice policies as outlined in our Financial Agreement Summary and Practice brochures.

You agree to inform Anchor Medical Associates of any changes to your name, address, contact information or insurance coverage. You may do this by using our patient portal or by calling your provider’s office as listed:

Providence Medicine Providers: 401-793-8400

Lincoln Medicine Providers: 401-793-8500

Lincoln Pediatric Providers: 401-793-8484

Warwick Adult/Pediatric Medicine Providers: 401-793-8520

Anchor Medical Associates is recognized as a Patient Centered Medical Home (PCMH) practice by the National Committee for Quality Assurance (NCQA), an organization dedicated to enhancing health care quality and safety. At a PCMH practice, patients receive quality care through a direct and long-term relationship with their chosen provider and health care team. Everyone at Anchor Medical Associates, both providers and staff, play a role in creating a PCMH practice that supports whole-person care.

Part of our obligation as a PCMH practice is to inform you of the following patient rights and responsibilities.

YOUR RIGHTS AS A PATIENT

You have the right to receive information about Anchor Medical Associates, its services, and its providers.

You have the right to be treated with dignity and respect and acknowledged as an individual with unique health care needs.

You have the right to respectful personal attention without regard to your race, national origin, gender, age, sexual orientation, language preference, religious affiliation, or pre-existing conditions.

You have the right to receive an understandable explanation of your health condition or status.

You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

You have the right to actively participate with your providers in decision-making regarding your health care.

You have the right to seek second opinions and we encourage you to discuss this with your provider.

You have the right to consent to or refuse any care or treatment.

You have the right to privacy of all records and communications to the extent required by law. Anchor Medical Associates providers and staff follow a strict confidentiality policy regarding all patient information.

You have the right to express any concerns you may have about Anchor Medical Associates, or the care provided by its providers or staff.

You have the right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.

YOUR RESPONSIBILITIES AS A PATIENT

You agree to choose a Primary Care Provider (PCP) who will direct your care, when coming to Anchor Medical Associates for primary care services.

You agree to meet with other members of your care team as the services they provide are vital to providing you with high quality, comprehensive care.

You agree to treat Anchor Medical Associates’ providers and staff with courtesy and respect.

You agree to be honest about your medical, dental, sexual, and mental health history.

You agree to disclose a complete health history and all current medications to your providers.

You agree to ask questions until you understand what you need to know about your health care.

You agree to follow health advice and medical instructions and express any concerns about your ability to follow the proposed plan of care.

You agree to report any changes in your health condition to your medical providers.

You agree to provide feedback about your service needs and expectations.

You agree to comply with our practice policies as outlined in our Financial Agreement Summary and Practice brochures.

You agree to inform Anchor Medical Associates of any changes to your name, address, contact information or insurance coverage. You may do this by using our patient portal or by calling your provider’s office as listed:

Providence Medicine Providers: 401-793-8400

Lincoln Medicine Providers: 401-793-8500

Lincoln Pediatric Providers: 401-793-8484

Warwick Adult/Pediatric Medicine Providers: 401-793-8520

Patient Financial Agreement

Our primary goal is to provide you with quality health care. In order to allow our staff to focus on your health care, we have developed the following policies regarding payment for services.

PATIENT RESPONSIBILITIES

It is your responsibility to provide us with accurate billing information for all of your health insurance plans for each family member at all visits.

If your insurance policy requires you to choose a primary care provider (PCP), it is your responsibility to ensure that an Anchor Medical PCP is on file with your insurance carrier prior to your visit.

Our central billing office staff is available to provide you with assistance, but cannot resolve disputes between you and your insurance carrier.

If your insurance policy requires a referral from your PCP, it is your responsibility to contact our office prior to seeing a specialist. If you are seeing us for specialty care, it is your responsiblity to get a referral prior to your visit.

It is your responsibility to keep your scheduled appointments. If you need to cancel or reschedule your appointment, please contact our office at least 24 hours prior to your appointment to cancel an appointment. Missed appointments may result in additional charges or dismissal from our practice.

PREPARATION OF FORMS

In keeping with community medical practices, in many cases we will charge a fee in advance for completion of special forms. Insurance carriers do not cover these fees.

COPAYMENTS/DEDUCTIBLES

Your insurance carrier requires you to pay your copayment at the time of each visit.

Your copayment may be paid with cash, check, Discover, Master Card/VISA credit or debit card, or money order. If you do not pay your required copayment at the time of your visit, a $15 billing fee will be assessed.

If your child comes for an office visit without a parent, he/she will still be responsible for the copayment at the time of the visit.

If another family member is financially responsible for payment, regardless of any child support agreements, you will still be responsible to pay the copayment at the time of visit.

If your check is returned, a $25 fee will be assessed. After two returned checks, you will be required to pay by cash, credit card or certified check only.

It is your responsibility to understand any deductibles that may apply to you under your insurance policy. If you have an unmet high deductible, we request a $75 deposit per visit.

PATIENT BILLS

If you do not have insurance coverage, you will be expected to pay at the time of visit.

If we cannot verify your insurance coverage at the time of your visit, we require a minimum $75 deposit per visit.

For balances over $10, you will receive a statement from our billing service indicating the amount your insurance carrier has determined you owe us as a result of any deductible, coinsurance or non-covered services. Balances under $10 will be collected at your visit and may not generate a bill.

Past due balances may also be paid through your patient portal account with Discover, Master Card/VISA credit card or debit card.

Unpaid amounts will automatically be sent to a collection agency after three statements. Our collection agency may report delinquent accounts to credit bureaus. If your account has been sent to collections, you will be responsible for collection fees and attorney fees, in addition to the original charges.

Please discuss financial hardship with our central billing staff as soon as possible, so that we may assist you in making arrangements for payment.

INSURANCE INFORMATION

Your insurance carrier requires you to present your insurance card and valid identification at the time of every visit.

It is your responsibility to ensure that we have accurate insurance information prior to receiving care from our providers. If an insurance claim is rejected as a result of incorrect information you provided (or failed to provide), you are responsible for payment.

Medical insurance does not always cover the entire cost of your medical care. In some cases, we do not learn that a service is not covered until after we submit a bill. If we believe a service we offer is not covered by your insurance, we will tell you. You are responsible for payment if your insurance carrier does not pay for a service.

Anchor Medical will submit claims to your insurance carrier on your behalf. You give us permission to provide your insurer(s) with any information necessary for payment. You give us permission to ask your insurer to pay us directly for care we provide.

If you have multiple insurance policies, you must inform us of each and every policy for each family member. It is your responsibility to know which insurer is primary and to inform us.

HOME ADDRESS AND TELEPHONE

We ask patients to complete a patient registration form annually, and any time there are changes to your contact or insurance information. Information on this form allows us to accurately maintain your account with us.

If another person is legally responsible for your bills, it is important that we have accurate information on your guarantor.

Appointments after 5 PM on weekdays and anytime on weekends or holidays incur an additional standard charge. Some insurance companies consider this to be the patient's responsibility and pass the charge on to you. Please contact your insurance company if you have any questions about your coverage for evenings, weekends, and holiday visits.