Family Medicine of Michigan is a BCBSM designated Patient-Centered Medical Home. This means that we have established policies and procedures to create and maintain a partnership with patients for the care we provide. We make every effort to ensure that the health care we provide includes preventive care as well as acute and chronic disease management and we put you at the center of that care.
This is not an exhaustive list of all of the office policies and procedures. Feel free to contact our office to clarify any of the information prior to submitting your new patient forms.
Please be advised that completing preliminary health and insurance questionnaires does not establish a physician-patient relationship with FMOM.
- Newly accepted applicants are not considered patients until they have been seen by a provider for the new patient physical appointment.
- Any patient that has had a three year absence and has not had an appointment by a provider in our office will not be considered a patient. Former patients that would like to be reestablished as patients will need to go through our New Patient process and be reaccepted.
- While Family Medicine of Michigan verifies your insurance, patients are responsible for understanding the terms of their medical insurance contracts and if a service that we provide is a covered contract benefit. Patients are responsible for payment if a service is rendered and the medical insurance denies payment.
- We keep same day appointments available for our patient’s acute care needs. However, you may need to see a provider other than your regular provider for these appointments depending on schedules.
- Family Medicine of Michigan does not allow patients to incur balances on an account. All patients must have an account guarantor and a secure method of payment on file that guarantees payment for services rendered. Any time a payment method does not satisfy a charge and a statement has to be generated there will be a $5 statement fee assessed. The Practice Financial Policy and Practice Family Account Policy are available online.
- Co-pays and any outstanding balance MUST be paid at the time services are rendered. Family Medicine of Michigan reserves the right to reschedule your appointment if you do not have payment or do not have a method of secure payment on file for co-pays, co-ins, deductible amounts, or balances on the day of your appointment. We may not process medical or administrative requests for services if there is an outstanding balance on your family account. The Practice Family Account Policy is available online.
- We will accept refill requests via telephone, fax, or online but it may take up to 72 hours for processing. It may also be required for you to have an office visit with your provider in order to process a refill request.
- All refill requests for controlled substances must be made with your primary prescribing physician at the time of your regularly scheduled appointment. No other requests for refills of controlled substance medications will be processed. The Practice Controlled Medication Policy is available online.
- WE CANNOT SEE YOU IF YOU HAVE MEDICAID INSURANCE. Medicaid requires that you see one of their participating providers for services. We do not participate with Medicaid and cannot accept any patients that have Medicaid insurance either as primary or as secondary insurance.
- FAMILY MEDICINE WILL NOT MANAGE CHRONIC PAIN MEDICATIONS. The providers will assess your condition and work toward resolving it with you. However, we normally refer to a pain specialist for management of chronic pain conditions and prescribing chronic pain medications.
- Chiropractic care services are not generally a treatment option we employ. Even if your insurance covers Chiropractic services we will generally not elect to refer you for treatment by a Chiropractor.
- We seldom refill medications for more than six (6) months at a time, therefore regular checkup appointments will be necessary for all maintenance medications. We do not call in prescriptions for new medications over the phone and will not make any changes to medications without an appointment.
- FAMILY MEDICINE OF MICHIGAN HAS A NO SHOW POLICY. Any time you fail to give us a 24-hour notice of a cancellation, the missed appointment will be considered a No-Show Appointment. More than three (3) No-Show appointments in a one-year period may result in termination of our relationship. Reminder notifications of your appointments are considered a courtesy. It is ultimately the patient’s responsibility to maintain all appointments. FMOM does not have a cancellation line when the phone lines are closed. The Practice No-Show Policy is available online. A MISSED NEW PATIENT APPOINTMENT WILL NOT BE RESCHEDULED.
No-Show fees are as follows:
$25.00 for a missed general appointment
$100.00 for a missed Physical / Health Maintenance Exam (HME)
This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.
Protected health information (PHI), about you, is maintained as a written &/or electronic record of your contacts or visits for healthcare services with Family Medicine of Michigan. Specifically, “PHI” is information about you, including demographic information (i.e. name, address, phone, etc.) that may identify you and relates to your past, present or future physical or mental health condition and related health care services.
Family Medicine of Michigan is required to follow specific rules on maintaining the confidentiality of your PHI, using your information and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.
If you have any questions about this Notice, please contact our Privacy Manager.
YOUR RIGHTS UNDER THE PRIVACY RULE
Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information (PHI). Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices – We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous place within our office and website (www.familymedicineofmichigan.com).
You have the right to authorize other use and disclosure – This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or FMOM has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to designate a personal representative – This means you may designate a person with the delegated authority to consent to or authorize the use or disclosure of protected health information.
You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e.portal, telephone, etc.) and to a destination (i.e. cell phone number, alternative address, etc.) designated by you. You must inform us in writing how you wish to be contacted (using a form provided by FMOM), if other than the address &/or phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and copy your PHI – This means you may inspect and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state or federal guidelines.
You have the right to request a restriction of your PHI – This means you may ask us, in writing, not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you or someone on your behalf, has paid for, in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.
You may have the right to request an amendment to your PHI – This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request for an amendment.
You have the right to request disclosure accountability – This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of FMOM.
You have the right to receive a privacy breach notice – You have the right to receive written notification if FMOM discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.
HOW WE MAY USE OR DISCLOSE PROTECTED HEALTH INFORMATION
Following are examples of uses and disclosures of your PHI information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by FMOM.
Treatment – We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other healthcare providers who may be involved in your care and treatment.
Special Notices – We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact your by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each notice will include instructions of opting out.
Payment – Your PHI information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits.
Healthcare Operations – We may use or disclose, as needed, your PHI in order to support the business activities of FMOM. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.
Health Information Organizations – Family Medicine of Michigan may elect to use a health information organization or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment or healthcare operations.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES
We may also use and disclose your protected health information (PHI) in the following instances as outlined below.
To Others Involved in Your Healthcare – We may disclose to a member of your family, a relative, a close friend or any other person, that you identify by completing a signed release of information, any PHI that you authorize. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care, general condition, or death. In any case, only the PHI that is necessary will be disclosed. Under Michigan law, however, we would only disclose health information related to a minor’s treatment for venereal diseases and HIV testing, substance abuse, behavioral health and prenatal/pregnancy treatment for those reasons required by law.
As Required By Law – We may use or disclose your PHI to the extent that the use or disclosure is required by law.
For Public Health – We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.
For Communicable Diseases – We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
For Health Oversight – We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.
In Cases of Abuse or Neglect – We may disclose your PHI to a public health authority that is authorized by law to receive reports or child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.
To the Food and Drug Administration – We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, to monitor product defects or problems, to report biologic product deviations, to track products, to enable product recalls, to make repairs or replacements or to conduct post-marketing surveillance, as required.
To Coroners, Funeral Directors, and Organ Donations – We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
To Law Enforcement – We may also disclose PHI, as long as applicable legal requirements are met, for law enforcement purposes.
For Legal Proceedings – We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
For Research – We may disclose your PHI to researchers when an institutional review board has reviewed and approved the research proposal and established protocols to ensure the privacy of PHI.
In Cases of Criminal Activity – Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
For Military Activity and National Security – When the appropriate conditions apply, we may useor disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service.
For Workers’ Compensation – Your PHI may be disclosed by us, as authorized, to comply with workers’ compensation laws and other similar legally-established programs.
When an Inmate – We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.
Required Uses and Disclosures – Under the law, we must make disclosures about you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.
You have the right to address complaints to us or to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Manager of your complaint at:
Revised Date 07/8/2015
Other than routine web transaction information that is automatically collected and stored (see below) – we do not collect information about you unless you choose to provide information to us.
Once we receive your transmission of personal information, FMOM treats the information as confidential.
Our system routinely collects information about site navigation and browser of web site visitors. We also collect data on search terms you used to find information on this web site, the pages you visited, and the address of the web site from which you came to visit. This information is used for trend analysis to help make this web site more useful to visitors. We do not collect any identifying or personal data on site users unless that information is submitted in request for services, programs or information.
You do not have to give us personal information to visit this web site. If you choose to provide additional information via an e-mail message, form, survey, etc. we only maintain the information for as long as needed to fulfill your request, or to track surveys and forms on the web site.
FMOM does not disclose, give, sell or transfer any personal information about our website visitors, unless required by law enforcement or statute.
When you submit personal information to FMOM through the Patient Portal, the Patient Portal encrypts the information using encryption technology which is the industry standard means to protect information that passes over the web to FMOM’s server. FMOM’s encryption is provided through a SSL certificate, a protocol which is used to communicate over the Internet in a secure fashion.
While FMOM is committed to enhancing security through use of encryption technology, at this time no data transmission over the Internet can be made 100% secure. FMOM cannot ensure that encryption technologies are undecipherable or that servers on or off FMOM premises are impenetrable. FMOM will not be liable for disclosures of your personal information as a result of interrupted transmission or unauthorized acts of a third party.
Online Credit Card Payments
FMOM uses Navicure Greenlight to process online credit card payments. Navicure adheres to strict PCI compliance standards for encrypted transmission. Navicure utilizes Trustwave to ensure strict PCI Compliance. PCI compliance is the Payment Card Industry (PCI) Data Security Standard (DDS) requirements for merchants that store, process or transmit cardholder data.
Sensitive credit card information is not stored in our office. It is stored on a secure website called a gateway that is completely compliant as required by law. We access your information only on this site to process a payment. The secure method of payment will not be kept along with patient medical records and any payment method ID numbers will not be stored on site, nor within the EMR/PM system, nor be visible to Family Medicine of Michigan staff once the payment method has been captured.
Other Web Sites
FMOM makes these links available to provide additional health care information and services. Links to third party sites are provided as a convenience to you. FMOM does not exercise control over content, software, or products found on linked sites.
Family Medicine of Michigan HIPAA Privacy Practices
FMOM offers information on this web site for general educational purposes only. This information should not be used for diagnosis and treatment, nor should it be considered a replacement for counsel with your physician or other health care professional. If you have questions or concerns about your health, contact your health care provider.
While FMOM makes every effort to ensure accuracy of the information on this web site, we do not guarantee the accuracy, and the information is provided without warranty or guarantee of any kind.
Family Medicine of Michigan is committed to meeting our patient’s healthcare needs and keeping their insurance and other financial arrangements simple, secure, and efficient. In order to accomplish this in a cost effective manner we have set forth the following terms we expect adherence to by patients and staff members.
- Patients will be assigned to a Family Account in accordance with the Practice Family Account Policy.
- Patients must provide proper identification, current address, telephone number, email address and current insurance information upon request and at least every visit.
- Patients must provide an individual Guarantor who must provide a secure method of payment to be kept on file in accordance with the Practice Family Account Policy. The secure method of payment will not be kept along with patient medical records and any payment method ID numbers will not be stored on site, nor within the EMR/PM system, nor be visible to Family Medicine of Michigan staff once the payment method has been captured.
- All copay amounts are due and payable at the time of service and are to be collected prior to the patient seeing a provider. Any and all outstanding balances are due, or written arrangements made and in place, prior to further services being rendered. Family Medicine of Michigan may elect to deny service (office visits, prescription refills, forms, etc.) for failure to pay copays at the time of service or outstanding balances upon demand and failure to provide guarantor information and payment method on file.
- Family Medicine of Michigan will submit claims to a patient’s health insurance carrier for payment of services rendered and follow existing participation agreement procedures for filing of claims as long as there is an acceptable form of secure payment on file that will satisfy any amount left unpaid (most commonly due to co-insurance or deductible amounts) after the claim has been adjudicated or a maximum of 45 days from the date claims were filed. Any and all outstanding amounts will be recouped via the secure payment method on file.
- Payments and adjustments to claims submitted to insurance carriers on behalf of patients will be applied to the charges for services rendered pursuant to any participation agreement (if exists) between Family Medicine of Michigan and the patient’s health insurance company. If no contractual agreement exists the full amount of the charges for services rendered will be due and payable.
- Uninsured patients must sign the Guarantor Agreement and provide a secure payment method prior to services being rendered and the amount owed for services will be recouped from the secure payment method as soon as the actual charge amount has been determined (usually 2 – 5 business days after the visit or services rendered).
- If the full amount of the fee for services is not satisfied by the secure method of payment on file a statement will be generated for any outstanding amounts owed. The statement may be mailed or communicated electronically to the account guarantor and is considered due upon receipt. Any time a statement is generated there will be a $5 statement fee charged to the account.
- Family Medicine of Michigan will do its best to communicate with patients and guarantors through all means available (statements, email, telephone, in person) any outstanding balances and work to resolve those balances to mutually beneficial arrangements.
- Any time an account has an outstanding balance that is left unpaid for more than 60 days from the date of service Family Medicine of Michigan may pursue all legal and credit action against the account guarantor and deny any and all further services to all patients on the account.
- If a credit balance is found to exist on an account the practice will first apply the credit to the oldest outstanding charge on the account across all patients in the account. If all charges have been satisfied and a credit balance still exists then the practice will issue a refund to the appropriate person (the payee of the originating payment that resulted in a credit or the account guarantor) in the form of a check and mail it to the appropriate person or the guarantor address on file unless other arrangements are made by the original payee or the account guarantor.
April 1, 2015
Family Medicine of Michigan is committed to meeting our patient’s healthcare needs and keeping their insurance and other financial arrangements simple, secure, and efficient. In order to accomplish this in a cost effective manner we have set forth the following terms outlining how patient financial accounts are established and maintained.
- Family Medicine of Michigan utilizes an Electronic Medical Record (EMR) and Electronic Practice Management (PM) system to store all patient health and financial information related to services provided at the practice.
- The practice will use its EMR and PM system to automatically assign a unique Patient ID number to all patients upon creation of a patient in the system according to the Practice Patient ID Creation Policy.
- The practice will utilize Family Accounts assigning all members of a family to a single financial account. An Account ID number will be assigned to each family account that is separate from the Patient ID number of the patient. Each patient under the family account will have the same Account ID number but will always retain their individual and unique Patient ID number.
- The practice EMR and PM system will automatically generate Account ID numbers upon creation of a new account. The system will generate Account ID numbers in whole integers starting at 1 and increasing by 1 each time a new account is created.
- Family account members will consist of all members of a household residence and/or those having coverage under the same insurance policy.
- Patients must designate a single individual as Guarantor who will agree in writing to be responsible for payment of all services relating to the patient within the Family Account by signing the Guarantor Agreement.
- Guarantors must provide a secure method of payment to be kept on file and sign the Practice Secure Payment Method Authorization form
- Family Medicine of Michigan will employ a third party payment agent to maintain the security of the payment method for each account according to the rules and standards set forth by applicable federal and state laws.
- Family Medicine of Michigan reserves the right to deny service if a secure payment method is not current and or if a guarantor is not established.
- Family Medicine of Michigan considers the following to be acceptable secure methods of payment: Credit/Debit/HSA/FSA card, Bank Account/Bank Draft, and cash.
- Family Medicine of Michigan has the right to approve or deny any requests for assignment to a specific Family Account of a patient that does not reside with the other members in the Family Account nor is covered under the same health insurance policy.
- A patient may be removed from a family account and assigned to a new or different family account only if the patient has separated from the family residence and or is no longer covered under the same health insurance policy.
- In the event an existing patient is assigned to a new or different family account, the patient will retain their original Patient ID number but a new Financial Account ID number will be assigned in accordance with the terms of this policy.
- Account Activity and History Reports will include financial account information for all members of the family account as of the date of the report. Family Medicine of Michigan will use only the minimally necessary identifiable information to keep the charges and credits under the account identifiable to each individual patient’s services. Any member of the account will have the ability to request and receive financial information on the account and will be able to view all of the account information.
Family Medicine of Michigan is committed to meeting our patient’s healthcare needs and keeping their insurance and other financial arrangements simple, secure, and efficient. In order to accomplish this in a cost effective manner we have set forth the following terms that establish how Patient ID numbers are created, established and maintained.
- Family Medicine of Michigan utilizes an Electronic Medical Record (EMR) and Electronic Practice Management (PM) system to store all patient health and financial information related to services provided at the practice.
- Family Medicine of Michigan will use the Electronic Medical Record (EMR) and Electronic Practice Management (PM) system to create individual and unique Patient ID numbers and associate patient medical records with that Patient ID number into what is commonly referred to as the Patient Chart.
- The Patient ID numbers will be numeric whole integers starting at 1 and increasing at a rate of 1 each time a new Patient ID is created.
- Required Demographic Information for a Patient ID Number:
- A patient must provide the practice with their current address of residence, telephone number, email address, sex, date of birth, emergency contact, medical release of information, and any applicable insurance coverage numbers.
- Patients must provide a valid current photo ID to be scanned into the patient record such as Drivers License, Passport, School ID, Military ID for purposes of ongoing identity verification.
- Patients must agree to inform the practice of any changes to this information as changes occur.
- The practice may elect to deny services for incorrect or inaccurate information.
- Other Demographic Information:
- Patients may be asked to provide other social, family, and economic information such as race, ethnicity, marital status, etc., but this other demographic information will not be considered a requirement for Patient ID Number creation.
- Patient ID’s for Minor’s can be created upon request of the parent or legal guardian of the minor. All Required Demographic information concerning the minor patient must still be obtained as per 4.1. above. If the minor does not have a photo ID then the photo ID of the parent or legal guardian will be scanned into the minor record for help in identification. As soon as a photo ID is available for the minor that will be scanned into the patient record and replace the parent or legal guardian photo ID.
If you do not show up for your scheduled appointment, and you have not notified us at least 24 hours in advance, you will be required to pay a $25 cancellation fee for regular appointments and $100 for physicals.
Family Medicine of Michigan’s No Show Policy is as follows:
$25 for a missed general appointment $100 for a missed Health Maintenance Exam
Family Medicine of Michigan requires a 24-hour notice for appointment cancellations or a No Show fee will be assessed.
Please note: We do not have the ability to accept phone cancellations outside of our business hours. More than three (3) No Show Appointments could result in the termination of our relationship.
AGS Beer’s Criteria for Potentially Inappropriate Medication Use in Older Adults
To: Medicare Recipients
In 2011, the American Geriatrics Society issued a listing of medications that were deemed to be potentially inappropriate for use in older adults usually on the pretense they could cause sedation and increase the risk of falling. Since that time, many Medicare plans have decided to require a prior authorization for the medications that appear on the list. While the decision to prescribe these medication is still a matter between the patient and their physician, but the decision as to rather or not your insurance company will pay for such prescribed medications is not.
Family medicine of Michigan will not pursue prior authorization for these medications any longer. Exceptions will only be made when a provider and patient have an office visit whereat previous drug failures and medical necessity has been thoroughly documented so as to clearly support the need for this specific medication. Documentation of the potential risks associated with the use of such medication will be recorded. However, please be aware that this still will not guarantee that a prior authorization will be approved by your insurance company; it merely is a requirement to initiate the prior authorization process.
FMOM strongly recommends that you visit any of the prescription drug websites (ex. www.rxpricequotes.com) to locate a local pharmacy and the pricing they are offering for your desired medication. You will find, in the majority of these situations, the cash pay cost of the medication is less than $25 for a 90 supply and will cost very little more than obtaining the medication through a prescription plan. You will need to notify the pharmacy that you will not be using your insurance prescription coverage plan and that you are exercising your right to pay cash for your prescription.
View a complete listing of medications found on the Beer’s list. The most commonly prescribed medication we have found that are prescribed from our office that fall under this category are Ambien, benzodiazepines (ex: Xanax, Klonopin, etc.) and estrogens.
David J. Smith, M.D.