Policies

For any additional questions please contact our office at (603) 386-0100

PATIENT RESPONSIBILITY POLICY INSURANCE REFERRAL POLICY

I understand that I am financially responsible for my health insurance deductible, co insurance or non-covered services.  Co-payments are due at time of service.  If my plan requires a referral, I must obtain it prior to my visit. In the event that my health plan determines a service to be not payable, I will be responsible for the complete charge and agree to pay the costs of all services provided within thirty days of billing statement. I understand that failure to provide payment may result in late fees, referral to a collections agency/lawyer and  discharge from the practice. I understand that an administration fee may be required in addition to any bank charges this office incurs for returned payments. I understand that it is my responsibility to change my primary care provider to a provider at Family Health Matters of Salem.  I understand that I will be responsible for the complete charge and agree to pay the costs of all services provided if I fail to do so. In the event that I provide insurance information that is knowingly termed and or incorrect I understand I am responsible for the full balance due. If I am uninsured, I agree to pay for the medical services rendered to me at time of service. I understand that in order to book an appointment I may be required to provide a deposit and or credit card to hold on file.

  • I understand that if I am here for my yearly physical exam and I am sick or have other concerns that need to be addressed, I may be required by my insurance company to pay a co-pay for my visit.  please read below

  • AN ANNUAL PHYSICAL EXAM CPE, WELL CHILD CHECK, MEDICARE WELLNESS IS MEANT TO BE A REVIEW OF YOUR SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY, AND ONGOING PROBLEMS. AT THIS TIME, YOUR INSURANCE COMPANY REQUESTS THAT WE ALSO ASSESS YOUR SAFETY, MENTAL HEALTH STATUS, TOBACCO AND ALCOHOL USE. THESE ASSESSMENTS ARE DONE WITH THE USE OF SPECIFIC QUESTIONAIRES THAT YOU WILL BE ASKED TO COMPLETE. IN ADDITION, WE WILL REVIEW ALL OF THE MEDICATIONS, SUPPLEMENTS, VITAMINS, AND RESPIRATORY DEVICES NEBULIZERS , OXYGEN, AND INHALERS THAT YOU ARE TAKING. WE WILL NEED TO KNOW IF YOU HAVE EXPERIENCED ANY ADVERSE REACTIONS TO MEDICATIONS AND WILL _update YOUR ALLERGY LIST INCLUDING NON MEDICINAL ALLERGIES. AT THIS VISIT YOU WILL BE ASKED TO CONFIRM ANY OTHER PROVIDERS THAT YOU ARE SEEING EYE DOCTORS, PODIATRISTS, CARDIOLOGISTS, ETC AND WILL INQUIRE ABOUT ANY CHANGES THEY MIGHT HAVE MADE TO YOUR TREATMENT PLAN. WE WILL CONFIRM PREVENTATIVE SCREENINGS INCLUDING BUT NOT LIMITED TO MAMMOGRAMS, BONE DENSITY, PAP SMEARS, COLONOSCOPY, ANNUAL STOOL TESTS, PROSTATE EXAMS, AND VACCINES. WE WILL REVIEW LABS THAT HAVE BEEN DONE SPECIFICALLY FOR THE VISIT IF AVAILABLE. FINALLY,YOU WILL HAVE A COMPLETE PHYSICAL HANDS ON EXAMINATION.

  • IF DURING THE COURSE OF YOUR VISIT, AN ABNORMALITY IS FOUND WHICH REQUIRES IMMEDIATE ATTENTION, YOU ARE EXPERIENCING AN URGENT PROBLEM, OR ARE SICK, THE PROVIDER MAY CHOOSE TO MANAGE THE PROBLEM ILLNESS  AND RESCHEDULE YOUR PHYSICAL EXAMINATION. PLEASE NOTE THAT YOUR INSURANCE COMPANY WILL NOT PAY FOR YOU TO HAVE BOTH A PHYSICAL EXAM AND A SICK VISIT.  THE INSURANCE WILL ALSO NOT PAY FOR A DISCUSSION OF NEW PROBLEMS AT THE TIME OF YOUR ANNUAL VISIT WITHOUT A SEPARATE AND DISTINCT APPOINTMENT. THIS MEANS THAT IF THE PROVIDER ADDRESSES THESE ISSUES YOU MAY RECEIVE A NOTICE FROM THE INSURANCE COMPANY THAT A PORTION OF YOUR VISIT IS BEING APPLIED TO YOUR ANNUAL DEDUCTIBLE. THIS WILL ALSO RESULT IN THE OFFICE BEING  MANDATED BY THE INSURANCE COMPANY TO COLLECT A COPAY FOR THAT PORTION OF THE VISIT. IN ORDER TO BEST TAKE CARE OF ALL OF YOUR NEEDS AN APPOINTMENT WILL BE SCHEDULED FOR YOU ON ANOTHER DAY. I understand that it is my responsibility to know what my insurance will cover in regard to labs tests, imaging, procedures, etc.I understand that there will be a co-pay collected for visits to refill controlled medications.I understand that it is my responsibility to know my insurance company’s referral policy in regard to the referral process. Please allow at least FIVE business days for a referral to be completed by our office. No retroactive referral will be allowed.  Contact your insurance carrier immediately if you have not followed the procedure for a referral. It is my responsibility to assure that the specialists or facility that this office recommends is in my network. If you go outside of your network, your claim could be denied and you would be responsible for any charges incurred at the visit. Please know what your insurance company states as their policy for urgent care and emergency room visits. Some policies require referrals for non emergent care.

I have read and understand the Patient Responsibility Policy/Insurance Referral Policy and agree to its terms.

LATE MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY

Thank you for trusting your medical care to Family Health Matters of Salem. When you schedule an appointment we set aside enough time to provide you with the highest quality of  care.  Should you need to cancel or reschedule an appointment please contact our office as soon as possible and no later than 24 hours prior to your schedule appointment.  This gives us time to schedule other patients who may be waiting for an appointment.

  • Any patient who fails to show or cancels reschedules an appointment and has not contacted our office with at least a 24 hours’ notice will be considered a no show and will be charged up to a $150.00 fee.

  • The no show or late cancellation fee must be paid PRIOR to being seen in the office for any future appointments.  We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment.  If you find yourself in this position please call to discuss the situation with our office manager.

  • Patients who miss three scheduled appointments without a 24hour notification may be asked to find another practice.

We promise to extend the same courtesies.  If we need to reschedule your appointment, we will advise you as soon as possible.  Unfortunately, there are times when weather emergencies, provider illness or a significant medical event, prevent us from providing a 24hour notice.  Our sincere hope and intention is that we never inconvenience you, but if that happens, we apologized and appreciate your understanding. Finally, we hope you understand that there are patients who occasionally need a little extra time and attention during their visit, which may cause a provider to run late.  If your provider is running behind, we will advise you at check-in and keep you informed as to your wait time.  Please be assured that you will have all the time you need during your appointment.

I have read and understand the Late Medical Appointment CancellationNo Show Policy and I agree to its terms.

TREATMENT OF MINOR

Any minor that comes into the office for an appointment will be seen.  However, please be advised that said minor will not receive any invasive treatment in the office such immunizations unless accompanied by his/her parent or legal guardian. This is at the discretion of the healthcare provider.  This may require referral to urgent care and or emergency room when indicated. Written permission from parent or guardian must be provided that indicates the adult over 18 years of age whom will be accompanying the minor to the office. This should include a full name and relation to the minor. A copy of the accompanying adults photo ID may be obtained for record. I have read and understand the Treatment of Minor Policy and I agree to its terms.

Controlled Medications

Pain Management, Mental Health, ADHD, Weight Loss and Use of ANY controlled Medications in New Hampshire now have strict regulations and guidelines, which have to be followed.  Patients with the need for treatment with controlled medications will need proper diagnosis following a complete workup including, but not limited to, physical exam, past medical and family social history, diagnostic testing and trials of different modalities of treatment.  In addition, a referral to a specialist for accurate diagnosing may be required prior to any initiation of treatment.

  • Initial assessment and diagnosis is mandatory for patients of all ages including, but not limited to, the completion of standardized screening exams such as SOAAP, the development of a comprehensive historical evaluation, a query of the history of refills as recorded by the NH pharmacy board, as well as the measurement of potential risk factors andor contraindications including randomized periodic drug screenings.

  • ADD ADHD for patients under the age of 18 years, a formal evaluation by a qualified provider is required.  Medications may be initiated at the discretion of the provider prior to evaluation in the best interest of the patient given the time frame for referral to such as qualified provider.

  • Weight Loss medication.  My provider has given me both verbal and written information about the risks and benefits of the prescribed medication.  I have made and informed decision to trial the weight loss medication.  I understand that there are potential side effects from the use of this medication including but not limited to nausea, vomiting, diarrhea, headache, and in specific cases the risk for medullary thyroid cancer and pancreatitis may be increased.  I have been given an opportunity to ask questions about these medications and have received answers to my satisfaction.

Prescription is defined as a medication legally authorized and dedicated primarily to the reduction of symptoms of a condition. Treatment is defined as the plan of care mutually decided upon between the patient and the provider to manage the symptoms of a condition.

  • All patients must have an annual complete physical exam

  • All patients must have a least one comprehensive follow up from the physical exam.  This is used to evaluate effectiveness of medications to ensure lowest effective dose is being used, continue to consider other treatment options, discuss risks and benefits of medication uses and discuss proper methods for discontinuation of medications if needed.

  • Prescriptions will be dispensed one at a time at your face to face.  At the discretion of the provider, patient can come in to pick up two additional scripts one month apart.  The 2nd and 3rd script will not require an office visit or co-pay.

  • Refills will be done within 48 hours and will require a visit in the office.  These refills will only be available during normal business hours.  These office visits will be used to review risks of side effects, including addiction and overdose resulting in death, risks of keeping unused medications, options for safely disposing of unused medications and dangers in operating motor vehicle or heavy machinery while using these medications. 

Potential risks or side effects of controlled medication treatment

  • Physical Dependence:  abrupt stopping of medication may lead to withdrawal symptoms, including abdominal cramping, pain, diarrhea, sweating, anxiety and aching.

  • Tolerance:  an effective dose of a controlled medication may become less effective over time even though there is no change in physical condition.  If this occurs progressively, your medication may need to be changed or discontinued.

  • Addiction:  more common in people with personal or family history of addition but can occur in anyone. Suggested by craving and compulsive use, despite negative consequences of use.

  • Overdose:  taking more than prescribed amount of medication or using with alcohol or other drugs can result in coma, brain damage or even death.

  • Risk to unborn child:  known and unknown risks to unborn children may include likely physical dependence at birth and possible alterations in later development.  You must tell your provider if you intend to become pregnant while on these controlled medications.

Reason for review and signing of this document

  • Misuse of controlled medications may result in serious harm to the individual patients or those around them and, when the medications are diverted, to the public at large.  Controlled medication usage has increased in the recent years injury and death due to misuse of these have also increased.

  • Both patients and health care providers have a responsibility to assure that controlled medications are used in a manner that is therapeutic for the individual to whom they are prescribed and not used in a manner that results in harm.  This agreement is intended to provide important information on the potential benefits and risks of controlled medications, as well as to document a shared understanding of what is expected so that these medications are used in a way that is safe and effective in treating you.  This agreement is reviewed and signed by all patients in our practice who receive controlled medications on a long -term basis.

Reporting lost, stolen or misplaced prescription

  • The office will not replace prescriptions unless a formal police report has been filed.

  • The maintenance of a secure location for both the actual medications pills patches and the written prescriptions is 100% the patient’s responsibility.

Inappropriate use of prescribed medications

  • Medications used to treat symptoms of a patient’s condition are controlled and monitored by the department of Drug Enforcement Administration DEA

  • If at any time there is a suggestion that the prescriptions written and dispensed from this office are being misused, sold transferred or otherwise diverted from the original intention to only treat the patient whose name and proper dosing of the prescription was written out for the existing prescriptions if any will be voided and paper refills asked to be return ed.  No future prescription for controlled medications will be written.

  • Intentional violation of the use of medications for the treatment of a condition in which uses controlled medications may result in immediate termination from Family Health Matters of Salem practice.

Agreement for Controlled Medication Treatment- I agree to or represent the following:

  • I will use my medication(s) only as prescribed, for the purpose of:

  • I agree to keep my medication(s) safe and secure to avoid intentional or unintentional use or diversion by others.

  • I agree to not use any illegal drugs or abuse alcohol while being prescribed this/these controlled medications(s).

  • I agree not to share, sell, trade or in any way provide my medication(s) to others.

  • I agree to only receive controlled medication(s) from this practice.  If controlled medications are prescribed unexpectedly by another office (for example due to an accident or dental procedure), I must inform this office within 24 hours.

  • I agree to fill my controlled medication(s) at one pharmacy only (listed below).  I must inform this office within 24 hours if, for some reason, I use a pharmacy different from my usual one.

  • I agree to have urine drug screens on a random basis and as requested by my provider.  Controlled medications will be discontinued if illicit substances are identified, or if my medication is not found in my urine screen.

  • I agree to bring my controlled medication(s) to the office when requested.

  • I agree to participate in other treatment(s) agreed to with my provider and keep all appointments scheduled for my care.

  • I agree to permit this practice to communicate with other care providers, pharmacists and /or my significant other(s) as needed to assure controlled medications are being used appropriately and are beneficial to my health and well being.

  • I agree to follow the advice of the practitioners of FHM of Salem in regard to stopping controlled medications.

  • I understand that NO refills will be made for lost prescription or medications.

  • I agree to allow FHM to run an eligibility check through the ECW for all prescribed prescriptions.

Your controlled medications will be continued if they have a positive effect on your life and health and if you adhere to the responsibilities described above.  They may be discontinued if the goals of therapy are not being met, or if you experience negative consequences or side effects as a result of using them.  If you do not adhere to the elements of this agreement, your controlled medication may be terminated with appropriate taper of medication as necessary. Should you develop complications of controlled medication use, such as addiction, we will assist you in finding treatment.  Please be aware, however, that our practice cooperates fully with law enforcement, the US Drug Enforcement Agency and other agencies in the investigation of controlled substance –related crimes including sharing, selling, trading or other potentially harmful use of these powerful medications.

Consent to treatment and agreement responsibilities outlined above:

 I have reviewed this document and have been given the opportunity to have any questions answered.  I understand the possible benefits and risks of controlled medications and I accept the responsibilities described above. I have read and understand the Controlled Medications Policy and I agree to its terms

HIPPA

10        Patient Consent for Use and Disclosure of Protected Information

15      I hereby give my consent for Family Health Matters of Salem to use and         disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO) .  (The Notice of Privacy Practices provided by Family Health Matters of Salem describes such uses and disclosures more completely.)

20        I have the right to review the Notice of Privacy Practices prior to signing this consent.  Family Health Matters of Salem 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 Family Health Matters of Salem, 32 Stiles Road, Suite 103, Salem, NH 03079-2853

25        With this consent, Family Health Matters of Salem may call my home or other provided alternative location to discuss and or leave a message on voice mail or in person in reference to any items that assist the practice in carrying out the TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, telehealth visits both audio and visual, among others. Family Health Matters of Salem may send text messages to the phone numbers I have provided.

30        With this consent, Family Health Matters of Salem may mail to my home or other alternative location any items and assist the practice in carrying out the PTO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

35        With this consent, Family Health Matters of Salem may e-mail to my provided email address or other alternative location any items that assist the practice in carrying out the PTO, such as appointment reminder cards and patient statements.  I have the right to request that Family Health Matters of Salem restrict how it uses or discloses my PHI to carry out TPO.  The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

40        By signing this form, I am consenting to allow Family Health Matters of Salem to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.  If I do not sign this consent, or later revoke it, Family Health Matters of Salem may decline to provide treatment to me.

15       Note:  This document is a template only.  It does not reflect the requirements of your state’s laws.  You should consult with advisors (your state or local medical or specialty society, or legal or other counsel) familiar with your state’s privacy laws prior to using this document

20        Copyright 2002 Gates, Moore & Company.  Used with permission. The HIPAA Privacy Rule:  Three Key Forms.  Bush J. Family Practice Management.  February 2003:29-33, http://www.aafp.org/fpm/20030200/29theh.html.

ACCESS EXTERNAL PROVIDERS/FACILITIES

I agree to allow Family Health Matters of Salem to access external medical providers and facilities for the purpose of adding medical information to my eclinical works electronic record.I have read and understand the Access External Providers/Facilities Policy and I agree to its terms.

DISCHARGE POLICY

In order to maintain a therapeutic relationship there must be mutual respect amongst the providers, support staff, and patients alike.  Family Health Matters of Salem reserves the right to discharge any patient that may violate these standards. Additionally, patients may be asked to leave the practice for failure to provide accurate insurance information in a timely manner and or does not meet financial obligations for services rendered.