Office Policies & Procedures

The Children's Clinic of Winston-Salem (CCWS) is committed to providing you with exceptional care at a fair and reasonable cost. To best serve our patients, the following is the CCWS financial policy. CCWS reserves the right to change this financial policy at any time. A current policy will always be available upon request. Acknowledgement and understanding of the CCWS financial policy must be signed upon registering with our practice prior to your child's first appointment.

• Patient Responsibility:

1. You must provide insurance coverage information prior to any office visit. If the child is covered by more than one policy, you must notify our team of all active policies. It is the parents' responsibility to confirm coordination of benefits if more than one policy is active. Failure to coordinate benefits with each insurance policy may cause claim denials resulting in charges becoming patient responsibility.
2. Your health insurance policy is a contract between you and your insurance company. As a courtesy to CCWS patients, we will file claims to any insurance carrier with whom we are participating providers. This requires having accurate and up-to-date insurance information on file, so patients must notify us of any changes to your health insurance coverage.
3. Once your insurance company has processed a claim, you are responsible for any remaining balance. Patient responsibility includes co-payments, co-insurance, and deductible amounts and is determined by your contract with the insurance company. 
4. Co-pays and any outstanding balances will be collected in full at the time of service. The parent or caregiver bringing in the patient for service will be financially responsible for the bill, as payment is required at the time services are rendered.
5. Newborn babies need to be added to your insurance plan within 30 days to ensure coverage. After the 30 days, your insurance may not cover the child and you will be financially responsible for the cost of all care.

• Non-Covered Services:

1. CCWS will always provide your child with what we consider the best, most up-to-date medical care. Some insurance plans limit coverage of labs, procedures and services in order to control their costs. As a result, certain services we may provide for your child may not be reimbursed by your plan.
2. Except as provided by your insurance contract or by state law, you will be responsible for all non-covered services.

• Billing Inquiries:

1. If you believe your insurance company has made an error in processing a claim, we ask that you contact your insurance company as soon as possible.
2. If your company determines that an error has been made, please contact our billing staff so that we can resubmit the claim.

• Self-Pay Patients:

1. Self-Pay Patients without insurance coverage will be required to pay in full for all services at the time they are rendered.
2. A time of service discount will be offered to patients who pay in full for their visit at the time of service. We will not bill you for self-pay balances.

• Credit Card on File:

1. As part of CCWS’ commitment to making our billing process as efficient as possible, we request that families to keep a credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable. Without such authorization, outstanding charges remaining after 30 days will be subject to a $25.00 billing fee for any balances that we must attempt to collect through mail and other means.  And charges that are not paid within 90 days will be sent to our collection agency and may be reported to the major credit bureaus.
2. In order to avoid such charges, keeping your credit card authorization on file allows us to collect the balances (if any) once your insurer has processed claims for any services rendered. Once your card is charged, a receipt will be sent to you by email.
3. Your credit card information is kept confidential and highly secure, and payments to your card are processed only after the claim has been filed and processed by your insurer.
4. If you are experiencing financial difficulties, please contact our office to discuss installment payments for any balances due. A regular monthly payment schedule can avoid collection procedures and enable continuation of care in our office.

• Divorce/Separation:

1. In the case of divorce or separation, the parent authorizing treatment for their child will be the parent responsible for those subsequent charges. If a divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. 
2. If at any time there are legal changes to the party assuming financial responsibility for medical services received by your child due to changes in marital status or otherwise, it is your responsibility to fill out new paperwork with our office and to sign a new financial policy. Our office will not change financial responsibility on an account or bill another party without this signed paperwork.
3. Our office will be happy to provide receipts for paid medical bills for you upon request.

• Preventative Services:

1. Additional issues addressed at well-child appointments may need to be reported and billed separately. Your insurance company may require that a separate co-payment be paid for additional services provided at the visit.

• Additional Fees:

1. No Show Charge: There is a $50 late cancellation/no show charge for appointments canceled with less than 24-hour notice.
2. Declined Credit Card/Returned Checks Charge: Credit cards on file that are declined and/or checks returned for insufficient funds will be subject to a service charge of $25 being added to the original billed amount.
3. After Hours/Weekend/Holiday Charge: Weekend or holiday appointments will be available in certain circumstances and will be billed an after-hours fee to cover overtime staffing expenses. If your insurance company does not cover this fee, you will be responsible for payment.
4. Administrative Charges: The Comprehensive Administrative Family Plan bundles administrative fees to cover non-medical, non-reimbursed administrative services that are typically charged individually.

HIPAA omnibus notice of PRIVACY Practices

Effective as of August 1, 2023

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

YOUR RIGHTS:

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• You may complain to us or to the Secretary 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 Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

HIPAA Compliance Officer: Kirsten Davis, Practice Administrator          

Phone: (336)815-4890                         

Email: kdavis@childrensclinicws.com  

YOUR CHOICES:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES:

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

- Treat you

We can use your health information and share it with other professionals who are      treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

- Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

- Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Help with public health and safety issues:

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research:

We can use or share your information for health research.

Comply with the law:

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests:

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests:

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions:

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OUR RESPONSIBILITIES:

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will never share any substance abuse treatment records without your written permission.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.   We are also required to abide by the terms of the notice currently in effect.  If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

As medical professionals, we feel very strongly that vaccinating children may be the single most important health-promoting intervention that we perform as healthcare providers and that you can support as parents and caregivers. 

We encourage parents to share with us if you have any questions or concerns about vaccines.  We want you to understand why vaccines are so vital for your child's health, in order to feel confident in vaccinating your child according to the vaccination schedule endorsed by the American Academy of Pediatrics (AAP).  

• We firmly believe in the effectiveness of vaccines to prevent serious illness and save lives.
• We firmly believe in the safety of standard childhood vaccines. 

And therefore, 

• We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule recommended by the American Academy of Pediatrics (AAP).  We do not offer delayed or alternate vaccine schedules for our patients.

A parent requesting medical treatment is individually responsible for the payment of that visit’s medical bills.

CCWS is not a party to your divorce agreement; we will collect co-pays and deductibles from the attending parent, and will hold the attending parent responsible for any other payments associated with that visit.

“Joint Custody” means that each parent has equal access to the child’s medical record. Without a court order, we can not restrict either parent from access to their child’s medical information.

We will not call the other parent for consent prior to treatment, or to inform the non-present parent of the assessment and/or plan of care.

We will discuss information pertinent to the child’s history and exam with the accompanying parent at the time of the visit; it’s the parents’ responsibility to communicate with each other. For this and other reasons, we recommend that both parents have their own Patient Portal account, so each has access their child’s medical records at all times.

If a court order requires us to do otherwise, we will be happy to comply after we receive a copy of it, which we will enter in the child’s medical records.

Should issues between parents become disruptive to our medical practice, we reserve the right to discharge a family from our care.

Individuals at CCWS will not be discriminated against because of race, color, creed, religion, sex, age, sexual preference, national origin, citizenship, marital status, disability, veteran status, or any other status or characteristic protected under federal, state or local laws.

Acts of discrimination and/or harassment based on any of those factors are inconsistent with our philosophy and our core principles and will not be tolerated.