Call Us: (702) 228.9888
7720 West Sahara Avenue Suite 103 Las Vegas, NV 89117 Phone (702) 228-9888 Fax (866) 920-0799
Below are our office policies that would be given to you to read and sign acknowledgement in the office. If you would like to speed up the check-in process, please read the office policies and print/sign paperwork under the "forms" tab.
Notice and Acknowledgement HIPAA Information
The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient.
• Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
• It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
• You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.
• Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
• We agree to provide patients with access to their records in accordance with state and federal laws.
• We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
• You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
• A copy of the NV HIPAA Regulations and Guidelines are available upon Request from the front office staff.
I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to Sahara Family & Skin Clinic.
• We accept payment in the form of cash or debit/credit card.
• Payment is required for all services at the time they are rendered unless you are enrolled in an insurance plan in which we participate.
• Any applicable co-payments, co-insurances and/or deductibles will be collected at the time of service.
• Your insurance plan will be billed for the charges incurred.
• Please note that the patient is responsible for any/all charges not paid for by insurance company.
• Prior authorization does not guarantee payment of claims.
• If a diagnostic procedure is performed, it is the patient's financial responsibility to pay any balance due to any outside facility utilized to complete and determine the diagnosis for such procedure.
• $25 Fee to complete FMLA, Life, Disability, and many other various types of independent health forms.
I understand and agree that I will be personally and fully responsible for full payment for the services rendered if my insurance company denies payment for any reason.
• We ask that you schedule an appointment to have your prescriptions refilled.
• At your scheduled office visit, the provider will discuss appropriate monitoring intervals for your medications, and will make sure you have enough refills until the next planned office visit.
• When your medicine bottle shows: "No refills remain" or "Contact your physician for a refill," these should serve as a reminder that you need to come in and be seen.
• Some medications are best monitored with laboratory testing in addition to an office visit. These include cholesterol lowering medication, blood pressure and diabetes medication, and thyroid supplements. If you think you may need lab work prior to the office visit, have it drawn at least 3 days before the appointment so that we can use the appointment time more efficiently.
• Please bring either a printed list of your medication or the medicine bottles themselves to your appointment. Refill requests will only be taken at your office visit.
• Patients on Coumadin or warfarin are seen at least once a month for prothrombin time (PT, Protime) blood test. Please schedule a regular office visit to address any other medical problems. We can perform a Protime during those visits, as well.
You must notify the office with a minimum of 24 hour advanced notice to cancel or change your scheduled appointment. Failure to do so will result in a $25 fee. No-showing to scheduled appointments will also result in a $25 fee.
All sales, both products and services, are final. No exchanges or returns. NO EXCEPTIONS.
PATIENT-PHYSICIAN ARBITRATION AGREEMENT
ARTICLE 1: Agreement to arbitrate: It is understood that any dispute as to medical malpractice, that is to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly negligibly or incompetently rendered will be determined by submission or arbitration as provided by Nevada or resort to court process except as Nevada law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it are giving up their constitutional right to have such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
ARTICLE 2: All claims must be arbitrated: It is the intention of the parties whose claims may arise out of or relate to treatment services provided by the physician including any spouse or heirs of the patient and children. In case of any pregnant mother the term "patient" herein shall mean both the mother and mother's expected child or children.
ARTICLE 3: Procedures and Applicable law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator [party arbitrator] within thirty days a third arbitrator together. Each party to the arbitration incurred or approved by the neutral arbitrator, not including counsel fees of witness fees, or other expenses incurred by the third party for such party's own benefit. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joiner in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joiner any existing court action against such additional person or entity shall be stayed pending arbitrator. The parties agree to provisions of Nevada law applicable to health care provides shall apply to dispute with this arbitration agreement including, but not limited to code of civil procedure sections 340.5 and 667.7 and summary adjudication in accordance with the Code of Civil Procedure.
ARTICLE 4: General Provisions: All claims based upon the same incident transportation of related circumstances shall be arbitrated in one proceeding. As claim shall be waived and forever barred if  on the date notice thereof is received, the claim is asserted in a civil action, would be barred by applicable Nevada Statue of Limitations, or  the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for arbitration shall be governed by Nevada Code of Civil Procedure provisions relating to arbitration.
ARTICLE 5: Revocation: This agreement may be revoked by written notice delivered to the physician within thirty days of signature and is not revoked with govern all medical services received by the patient.
ARTICLE 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed [including but limited to, emergency treatment] patients should initial below.
If any provisions of this arbitration agreement are held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I acknowledge that I have received a copy.