want to make your visit as timely and helpful as possible. To that end,
we have developed the following policies and procedures:
Check-in: Please bring your insurance card to each appointment.
Insurance companies often will change your card, membership number or
insurance address, which must be accurate for you to obtain care. 2)
Update your contact information: On every visit our receptionist will
ask if your contact information has changed. Please make sure that we
have your current address and phone numbers, so that we may reach you
in case of emergency, to confirm your appointment or give you test
results. 3) Appointment no-shows: Please remember your appointments;
you are responsible whether or not we call to confirm. If you do not
arrive or call to cancel at least one hour before your scheduled
appointment, you may be charged $25. If you miss three or more
appointments, you may be asked to find another practitioner. If you are
more than 15 minutes late for your appointment, you may be asked to
reschedule. Missed or late appointments mean that other patients cannot
be seen or are delayed. 4) Billing: Bills for medical services are
payable on receipt. If your bill has not been paid within 90 days, your
account will be sent to collection. You are responsible to provide us
with correct information about your health insurance, and to pay any
balance not covered by your insurance. 5) Filling out forms: You may
be charged $15 per form for the physician to fill out personal forms
not directly related to your health care. We will not charge for forms
for state and federal disability and forms for public education and
other public agencies. 6) Conduct in the office: We care about
providing a healing environment, as we care for many sick people every
day. Behavior that is rude, disruptive or inappropriate to the
physicians, staff or other patients will not be tolerated and may
result in such a patient being asked to find another practitioner.
Please alert our office manager if you feel there is an issue. 7)
Prescription refills: Please ask your practitioner to refill your
medications at your appointment if needed. If you run out before your
next appointment, ask your pharmacist to contact our office for a
refill. We do not refill certain prescriptions (such as narcotics,
tranquilizers and sleeping pills) over the phone on nights and weekends. 8)
Advice Nurse: We have an advice nurse available from 9PM-7AM weekdays
and all day Saturdays and Sundays. In addition, there is always a
doctor on call, who can be paged by our answering service for urgent
matters. If you have a life-threatening emergency, you should call 911. 9)
Website: Check our website at www.bwfhc.yourmd.com for articles on
common medical conditions, ways to maintain good health, and
complementary approaches that you may find useful. 10) Online
consultations: Online consultations are available through our website.
Users must have prior approval from their practitioner; there is a
charge to use this service, which is not covered by most insurance.
Procedure Description: Flexible sigmoidoscopy is a visual examination of
What To Expect: The
procedure takes about 30 minutes. You will be lying on your side and
have some discomfort at certain points in the exam. You are usually
awake and can return home immediately after the procedure.
1) Buy 2 Fleets enemas and 1 box of Dulcolax tablets; these can be bought over the counter at the drugstore.
NIGHT BEFORE EXAM: Use 1 Fleets enema as directed, and take 4 Dulcolax
tablets. You will likely be going to the bathroom frequently after this.
3) MORNING OF EXAM: Use 1 Fleets enema 1 hour before you leave home. Please eat a light breakfast, juice, coffee or tea.
may have some cramping and gas that day. Occasionally there may be
slight rectal bleeding. You may eat whatever you want after the
Request for Access to Patient Health Information
Request for Patient Access to Health Information BayWest Family Health Care, 1580 Valencia St., Suite 201, San Francisco, CA 94110 Practice Administrator, (415) 550-0811 As
required by the Health Information Portability and Accountability Act
of 1996 and California law, you have a right to request the opportunity
to inspect and copy health information that pertains to you. We will
evaluate your request and will either grant it or explain the reason
why the request will not be granted. Your right to access does not
extend to information compiled in reasonable participation of, or for
use in, a civil, criminal or administrative action or proceeding, or to
information we received in confidence from someone other than another
health care provider. I hereby request access to health information for: ____________________________________________________________________ ____________________________________________________________________. (Print Patient?s name and address) If known: Year of birth: _________ SCOPE OF ACCESS REQUESTED I would like access to: ¨ All the records or ¨ The portion of the records concerning:
(Specify type of disease, accident, dates of treatment, or other portion of records you are interested in.) TYPE OF ACCESS REQUESTED ¨
Inspection. Please let me know when I may come to inspect the records,
and the amount of the charge, if any. I understand that an employee of
this medical practice may be present and that I may not make any marks
or alter the records in any way. ¨ Copies. I would like copies of ¨ All records requested or ¨ All records other than X-rays or tracings ¨ Transfer. Please transfer ¨ Copies of all records requested or ¨ Original X-rays or tracings only To: (Name and address of health care provider to whom the records are to be delivered) ¨
I would like the information in the following form or format if it is
readily produceable in this form:
_________________________________________________. CHARGES Inspection.
I understand that you may charge me for reasonable clerical costs
incurred in making the records available for inspection at a rate of
[$6.00] per quarter hour and I may be required to pay these costs
before I may inspect the records.
Copies or Transfer. I
understand that you may charge me a reasonable charge of up to
twenty-five cents ($0.25) per page, or fifty cents ($0.50) per page for
copies from microfilm, plus any additional reasonable clerical costs
incurred in making the records available. ¨ I hereby agree to pay the charges specified above. ¨ Please call me to let me know how much these copies will cost.
¨ I am requesting these records be provided without charge to appeal
the denial of eligibility for Medi-Cal, SSDI or SSI/SSP benefits. A
copy of the program's denial notice is attached. I applied for these
benefits on ___________ (date).
Signed: __________________________ Date: __________________________ Print Name: ______________________ Telephone: _____________________ If not signed by the patient, please indicate: Relationship: ¨ parent or guardian of minor patient ¨ guardian or conservator of an incompetent patient ¨ beneficiary or personal representative of deceased patient Name of Patient: _________________________________________