Transcript Document

Important
Registration and
Billing
Information
Schneider Regional Medical Center
9048 Sugar Estate
St. Thomas, VI 00802
www.srmedicalcenter.org
Welcome to Schneider Regional Medical Center
Patient Financial Services
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A hospital visit can often be a confusing time. Knowing what to
expect can really put your mind at ease. That’s why we’ve
made it one of our top priorities to keep you informed about
our processes, including our billing procedures.
We understand that a Hospital Stay or Outpatient testing can
be a time of concern and anxiety for you and your family.
Please take this opportunity to review some of the processes
that you may encounter.
You may be asked to sign in at the reception desk. Due to
clinical necessity there may be times when patients are
registered out of order. We will assist you with the same
urgency as soon as possible.
You are responsible for your own valuables and personal
items while you are in the hospital. Therefore we ask that
other than sufficient funds to meet your co-payment/deposit
requirements, you leave your valuables at home.
We will collect and file your insurance for you. Following your
visit or stay you will receive monthly bills telling you the status
of your claim. These bills will show what has been billed to
insurance and will not have a patient balance due on them.
We encourage payment of co-insurance and deductibles up
front or you may pay them at any time following your time
here.
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Insurance:
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Your co-pay, deductible and/or co-insurance are due at the
time of service. Payments can be made by cash, debit cards,
personal check, travelers check, EFT (Electronic Funds
Transfer) or by credit card (Visa, MasterCard and American
Express).
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If we do not have the exact amount due at time of service, we will
require a deposit. The deposit may vary, depending on the
particular type of service.
Medicare patients should be prepared to pay their inpatient
deductible at the time of admission.
“Medicare patients, we are required by Medicare to check the
diagnosis information that your ordering physician has provided
with the specific test or procedure he/she has ordered when you
are scheduled for Outpatient services. In some cases, Medicare will
not pay for a service because they feel that the diagnosis does not
support the need for the test or service requested by your
physician.”
Please have your insurance card (s) and proof of identification
readily available.
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Self-Pay: Patients with no insurance agree to pay estimated charges prior to
treatment. Because we realize that health care is expensive, self-pay patients are given an
automatic 40% discount at the time of billing. To obtain the estimated cost of your service, please
contact Patient Financial Service. Any additional charges incurred during the visit are the
patients’ responsibility. If you are a Self-Pay patient, all payments are expected at the time of
registration. If you are unable to pay, we will require a substantial deposit towards your care. The
amount of that deposit will be directly proportional to the class of service you are scheduled to
receive.
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Financial Assistance Programs (Federal, State and Local) are available). Patients or immediate
family members should contact a Financial Counselor for assistance.
Pre-Certification: Your insurance coverage is a contract between you
and your insurance company. Benefits will vary depending upon the type of insurance
policy you carry.
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If your insurance requires pre-certification or an authorization, we will attempt to obtain them for you
before your service (s), however, remember it is your responsibility to notify your insurance company
of services that require pre-authorization or pre-certification.
If we have not been able to obtain authorization, we may need to cancel or reschedule your service
(s).
Pre-Registration: We can pre-register any visit arranged in advance by a
physician. Through advance registration, all of the required information about you is gathered and
placed in our files pending your visit. Your service representative will discuss financial
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requirements with you at that time.
If your Physician schedules your service in advance, we will attempt to contact you to update
your demographic information before you arrive.
Your co-payment, deductible and co-insurance are due at the time we are pre-registering
you. Payment may be made by cash, check, or credit card.
If you would like to schedule any service (s) in the future and would like to contact us to preregister, please call 340-776-8311 and request Registration Services. Contact us at least (3)
days prior to your service.
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Registration: We offer services without regard to religion, race, sex, age,
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national origin, or handicap. Your Service Representative will help you complete the
appropriate paperwork required for your hospital visit.
Registration will consist of the following:
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A Confirmation of your demographic information
Verification that pre-certification has been obtained
Collection of payments that are due
Order for the test (s) requested by your Physician.
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Hospital Billing Guide: We are providing this guide to inform you of
what you can expect regarding hospital charges for services provided to you today, if you have
insurance.
Your hospitalization coverage is a contract between you and your commercial insurance company.
You are responsible for your hospital account.
We will bill your insurance on your behalf as a courtesy. Your coverage is a contract between you
and your insurance company. During the process of filing your claim, you will receive a variety of
letters to keep you informed of the status of your account.
Please be advised that you may obtain informational statements until your insurance company
correctly pays your claim. You may want to call your insurance company to see what is causing
the delay. In many instances, the insurance company is waiting for information from you or the
subscriber.
After receiving the insurance payment, you will receive an Explanation of Benefits from your
insurance company telling you how the claim was processed and informing you of your financial
responsibility (co-pays, deductibles, and/or co-insurance).
At the time the bill is sent you your insurance company, you will receive an itemized statement
from the hospital which will reflects your hospital care, and all the supplies and services ordered by
your physician. If you need an insurance billing form for billing other insurance, we can provide you
with a copy if you contact Patient Financial Services. However, your Hospital Bill must first be paid
in full.
Physician Billing: You should expect to receive a separate bill from the
Physician’s that may assist in caring for you.
During the course of your stay, your physician may request consultations and/or services of
hospital-based physicians including but not limited to, emergency physicians, radiologists,
pathologists, and anesthesiologists.
The physicians associated with this hospital may be independent, private practicing physicians,
and may be individually contracted with an insurance company. Contact your insurance company
to verify that both the Hospital and the Physician are contracted with your Insurance Provider
Network. You should expect to receive a separate bill from your Physician (s) listed below, if
applicable:
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Emergency Physicians: Will be billed via our billing system for
any services you may have received while in the Emergency Department.
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Radiologists: Will bill you for reading any X-rays that were
taken while at the hospital.
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Pathologists: Will bill you for any laboratory and pathology test
(s) they have read while you were at the hospital.
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Anesthesiologists: will bill you for services received during
any surgical procedures you may have undergone while at the
hospital.
Consent for Admission to Hospital, Medical Treatment,
Release of Records and Responsibility
Name:_____________________________________________
Date:___________________
Time:_____________________
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I/We the undersigned, knowing that _________ is suffering from a condition requiring diagnosis and medical or surgical treatment hereby
voluntarily consent to such diagnostic procedures and hospital care by or under the supervision of Dr. ______.
2.
I/We are aware that the practice of medicine or surgery is not an exact science and I/We acknowledge that no guarantees or assurances
have been made to me/us with regard to the results that may be obtained from treatments or examinations in the hospital.
3.
I/We acknowledge that the Schneider Regional Medical Center does not assume responsibility for loss or damage to personal property kept
in the patient’s room. I/We further acknowledge that while the safe is available for the keeping of money and valuables of the patient, the
Schneider Regional Medical Center assumes no responsibility for any possessions deposited therein.
4.
I/We consent to allow students from formal education programs for health care professions to participate in my/the patient’s care, under the
supervision of appropriately licensed an/or credentialed members of such disciplines.
5.
I/We acknowledge that I/We have received a written document regarding my/the patient’s rights under Virgin Islands law to make decisions
about my/the patient’s medical care, and specifically about advance directives, (i.e. living wills, etc.) NOTE: Included in this document is
information about the Schneider Regional Medical Center’s policies as regards advance directives.
6.
I/We consent to the release of information to friends, relatives and others who may inquire, information to be released includes: patient’s
name, admission or discharge, medical condition in general terms, hospital room and hospital phone number.
7.
If applicable, I/We authorize the Schneider Regional Medical Center’s pathologist to use his discretion in the disposal of any specimen or
tissue obtained from the patient during the course of diagnosis or treatment.
8.
If applicable, I/We consent to the administration of such anesthetics as are necessary and applied by or under the direction of the medical
anesthesia department. Note exceptions, if any____________________.
9.
I/We understand that some insurance companies require authorization for inpatient admissions or specific procedures, and that maximum
reimbursement may not be received if authorization is required and I/We do not have it, I/We assume the responsibility of obtaining such
authorization if necessary and understand that Schneider Regional Medical Center cannot obtain such authorization for me/us.
10.
I/We authorize Schneider Regional Medical Center and/or any doctor involved with my/the patient’s care including those performing
diagnostic radiology (x-ray) services, anesthesiology services, pathology services, emergency services, or other similar specialty services to
release any information from my/the patient’s medical record as requested by the patient’s insurance company for payment of the hospital’s
or physician’s accounts.
11.
I/We assign all insurance benefits due to or received by me/us to Schneider Regional Medical Center, and/or the doctors involved with
my/the patient’s care including those performing Radiology, Anesthesiology, Pathology or Emergency Services; or other similar specialty
services as total or partial payment for services provided. I/We understand that this assignment may not constitute full payment of my/the
patient’s bill, and does not relieve me/us from liability for the unpaid balance. If insurance benefits to which I/the patient (s) are entitled are
paid directly to me/us, such benefits will upon be immediately delivered to Schneider Regional Medical Center (or the appropriate physician)
by me/us until the full amount of all charges incurred are paid in full.
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I/We agree to pay directly to Schneider Regional Medical Center and/or such doctors the charges incurred for services rendered/received, at
their established rates. I/We will pay all attorney’s fees and court costs incurred by Schneider Regional Medical Center or such doctors in
collecting any unpaid balances for services I/the patient received.
DO NOT SIGN THIS FORM UNTIL YOU HAVE READ IT AND UNDERSTAND ITS CONTENTS
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(WITNESS)
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(SIGNATURE OF PATIENT)
(IF PATIENT IS UNABLE TO CONSENT OR IS A MINOR, COMPLETE THE FOLLOWING:)
Patient is a minor _____ years of age (or is unable to consent because: _______________________________________)
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(WITNESS)
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(SIGNATURE OF CLOSEST RELATIVE OR LEGAL GUARDIAN)
CONSENT FOR DELIVERY AND CARE OF NEWBORN
If applicable, I/We authorize the delivery, care, and treatment of both mother and newborn infant as explained by the designated physician (s).
I/We consent to the performance of any other procedures as are considered necessary by said physician on the basis of findings during the course
Of care and treatment of mother and/or infant. I/We specifically understand that I/We are consenting not only to my/the mother’s care, but the care of the newborn as well.
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(WITNESS)
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(SIGNATURE OF PATIENT)
(If patient is an un-emancipated minor, complete the following – in addition to the patient’s signature above: )
Patient is a minor _____ years of age (Or is unable to consent because: _________________________________________________ )
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(WITNESS)
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(SIGNATURE OF CLOSEST RELATIVE OR LEGAL GUARDIAN)
Medicare Information for our
Patients:
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Medicare fraud steals millions of dollars every year from the Medicare
program. Beneficiaries pay for it with higher premiums. Fraud occurs
when someone knowingly deceives or misrepresents themselves in a
way that could result in unauthorized payments being made. Fraud
schemes may be carried out by individuals, institutions, or groups of
individuals.
Medicare fraud includes, but is not limited to:
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Billing for more expensive services at a higher service fee than
was actually provided.
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Falsifying certificates of medical necessity, plans of treatment, and
medical records to justify payment.
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Billing for services not furnished.
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Soliciting, offering, or receiving a kickback.
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Billing separately for services that should be included in a single
service fee.
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Misrepresenting the diagnosis to justify payment.
Medicare is improving its capability to crack down on those who take
advantage of this program. We are using four methods to fight fraud
and abuse: prevention, early detection, coordination with other
government agencies, and prosecution of wrongdoers.
We need your help to stop Medicare fraud and abuse. You can help
protect Medicare and yourself by reporting all suspected instances of
fraud and abuse. When you receive payment notices from Medicare,
review them for errors. Make sure Medicare did not pay for services,
medical supplies, and/or equipment that you did not receive.
Reporting Medicare Fraud and Abuse:
If you have a questionable charge on your bill, call the provider, your
Fiscal Intermediary (for Part A bills) or your Medicare carrier (for Part B
bills). If you believe that a health care provider may be cheating or
abusing the Medicare program, call the Medicare carrier or
intermediary that sent you the payment notice. Their name, address,
and telephone number appear on the payment notice. After you call the
Medicare carrier or Fiscal Intermediary, you may also call the Inspector
General’s hotline at 1-800-HHS-TIPS (1-800-447-8477), or TTY for
hearing and speech impaired: 1-800-377-4950.
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From publication No. HCFA 10111
To Our Patients:
In accordance with the Admissions/Registration Policies and
Procedures of the Schneider Regional Medical Center, it is our
obligation to inform you and your family members of the following
policies involving:
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Patient’s Rights and Responsibilities
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Patient Advocacy Information
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Copy received Patient or Legal Guardian:_________________________
Date:______________
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Admitted by: ________________________________________________
Date:______________
Patient Rights & Responsibilities
The Schneider Regional Medical Center DBA Roy Lester Schneider Hospital, Myrah Keating Smith Community Health Center and
Charlotte Kimmelman Cancer Institute are dedicated to serving the whole patient regardless of race, creed, social or economic status,
believing that the rights and dignity of every patient must be protected and promoted with care. The hospital and health center endeavor
to protect the patient’s rights to privacy and keep patient records and communications confidential, in accordance with professional ethics
and the law. The Schneider Regional Medical Center organizations are committed to safeguarding the right of each patient to information
about and participation in decisions regarding medical care, and to promoting respect and dignity for all individuals. In the case of a
minor, the following rights and responsibilities are afforded the patient’s parent or guardian.
You Have the Right To:
•Considerate and respectful care,
which optimizes your comfort and
dignity throughout your treatment.
•Access to treatment regardless
of
gender,
age,
disability,
ethnicity, religion, or source of
payment. This includes the right
to supportive social and pastoral
services that respect your
personal value and belief system.
•Expect that every attempt will be
made to provide an interpreter, if
your spoken language is not
English, or if you are deaf or
hearing impaired.
•Receive aggressive, timely and
appropriate pain management
when indicated.
•Participate in the consideration
of ethical issues that arise in the
course of your care.
•Personal
privacy
and
confidentiality. Be free from all
forms of abuse or harassment,
including the right to access
protective services, if needed.
•Receive information about, and
an explanation of, your hospital
bill.
•Be treated by skilled,
compassionate,
caring
physicians, nurses, and
hospital staff.
•Act in partnership with
your health care providers
to
make
decisions
regarding your care.
•Know the names and roles
of the providers caring for
you.
•“Advance Directives”: you
have the right to formulate
an Advance Directive or to
appoint a surrogate to
make health care decisions
on your behalf.
•Be well informed about your
illness, possible treatments,
likely and unanticipated
outcomes, and to discuss
this information with your
healthcare provider.
•Be
advised
if
the
hospital/health
center
proposes to engage in
research projects affecting
your care or treatment, and
the right to refuse to
participate in such studies
without compromising the
quality of care you receive.
•Receive a high standard of
patient care and safety while
in the hospital setting. The
hospital/health center, your
doctor, and health care
professionals will protect
your safety and security as
much as possible.
•Request a copy of your
completed medical record and
obtain the copy within a
reasonable timeframe.
•Be free from chemical or
physical restraint except as
authorized by a physician or
in an emergency when
necessary to protect you or
others from injury.
•To know if this hospital/health
center has relationships with
outside parties that may influence
your treatment and care. These
relationships
may
be
with
educational institutions, other
health care providers, or insurers.
•Receive
appropriate
discharge teaching and
instruction for self-care,
including
awareness
of
community
resources
available
to
provide
supportive care.
•Informed
consent,
including the right to have
treatment
options
explained so that you
understand the benefits,
risks,
and
treatment
choices.
•Refuse treatment to the
extent permitted by ethics
and law, and to be
informed of the medical
consequences of your
action.
•To
obtain
pertinent
information information as
to any relationship of this
hospital/health center and
other
health
care
institutions
which
may
affect your care.
It Is Your Responsibility
To:
Be Part of Your Care
•Be as accurate and
complete as possible when
providing medical history
and treatment information.
•Inform your health care
provider if you have any
questions regarding care
and treatment.
•Partner with the health
care providers to develop
an appropriate plan of
care.
•Participate
in
the
designated plan of care.
•Notify your health care
providers
if
the
designated plan of care
cannot be followed.
•Provide a copy of your
“Advance Directive" to the
hospital/health center.
•Notify your health care
providers or the Patient
Representative
at
x2302/Administrator
MKSCHC 693-8900 if you
are not satisfied with the
care you received.
Respect and Consider
the Rights of Others
•Be considerate of the
rights of other patients
and their families.
•Be considerate of the
physicians
and
hospital/health
center
personnel.
•Provide
the
hospital/health center with
accurate
and
timely
information
concerning
the sources of payment
and ability to meet
financial
obligations
associated with care.
Ensuring
a
Hospital Stay
Safe
•The
single
most
important way you, as a
patient, can help to
prevent errors is to be an
active member of your
health care team. Speak
up! if you have any
questions or concerns.
•Discuss your concerns with your nurse, physician, or if you have a commendation or complaint about the quality of your care, you may call the
Hospital Operator to page the Patient Representative or after hours, page the Nursing Supervisor. At Myrah Keating, Contact the Administrator.
Patient Relations
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The Patient Relations Department at Schneider Regional Medical Center is here to serve as the
Patient’s Advocate. Our mission is to address questions or concerns you or your family members
may have about care, hospital policies and procedures, or the quality of hospital services. Patient
Relations representatives are also happy to receive compliments, suggestions, and other
recommendations that might improve the services provided by this facility.
Compliments: if you would like to thank a special staff member or volunteer who made your hospital
stay especially comfortable, Patient Relations can assist you. Our team members are energized by
receiving suggestions or recommendations for future improvements. A word of thanks from the
patients we care for helps to lift our spirits and morale! We encourage you to send cards, emails, or
any other correspondence about the service you may have received.
Grievances and Concerns: If you have a complaint, you may register it verbally or in writing with a
representative. Your particular concern will be investigated and a resolution will be provided as soon
as possible.
As a Medicare patient, you also have the right to have your grievance regarding quality of care or
premature discharge referred to and independently reviewed by the Virgin Islands Medical Institute
Peer Review Organization (VIMI PRO). If you would prefer to contact the VIMI PRO directly, you
may do so at 340.712.2400 or 712.2449. An independent review of your case will be conducted.
This procedure can be initiated at your request, via Patient Relations and the Office of the Medical
Director.
If you have a complaint regarding a HIPAA privacy violation, you may direct it to The Director of
Privacy, Compliance and Health Information Management, Ms. Patricia Lake-Blyden, RHIA at:
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In the even that you or your family would like to file your grievance outside of the Hospital’s internal
grievance process, you may forward your written grievance to:
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Commissioner of Health, or Designee
USVI Department of Health
9048 Sugar Estate, 5th Floor
St. Thomas, VI 00802
340.774.0117
When sharing your compliments and concerns with our department, please be sure to include your
name, date of stay, the unit, the nature of the issue, the names of any individuals whom you feel are
important to the issue at hand, and how you would like to see the matter resolved.
Our hospital also conducts Patient Satisfaction Surveys through a nationally recognized survey
research consultant firm: The Jackson Organization. After you have completed your service and
have been discharged, you may receive a call from the surveyors. Please feel free to share your
responses with them. They compile the important information that you share with them, and submit it
to our Hospital’s Administration so that we can continue to improve our services and processes.
Patient Relations Contact Information:
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Extension 2253
9048 Sugar Estate
St. Thomas, VI 00802
Christine deJongh-Lewis, MPH
Hours: Monday through Friday, 8 AM to 5 PM
Location: Schneider Regional Medical Center Administration
Mailing Address: 9048, Sugar Estate, St. Thomas, VI 00802
Telephone: 340.776.8311 x 2302, 2201
E-Mail: [email protected]
After hours and on weekends, in non-urgent situations, please leave a message. If you have an
emergency, please contact the Nursing Supervisor or Administrator on Duty.
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Rev 11/04
Medicare Appeals and Grievances
(Complaints)
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In the Original Medicare Plan: If you
are dissatisfied, you have a right to
appeal any decision concerning your
Medicare covered services in the
Original Medicare Plan. You can file an
appeal if you believe Medicare did not
pay enough for services or should have
paid for health care services you
received. Your appeal rights will be
detailed on the back of the Medicare
Summary Notice (MSN) or Explanation
of Medicare Benefits (EOMB) that is
mailed to you.
If you believe you are being discharged
too soon from a hospital, you have a
right to immediate review by the Peer
Review Organization. Peer Review
Organizations (PROs) are groups of
practicing doctors and other health care
professionals paid by the federal
government to monitor the care given to
Medicare patients. They are responsible
for reviewing beneficiary complaints
about the quality of care provided by
inpatient hospitals, hospital outpatient
departments and hospital emergency
rooms; skilled nursing facilities; home
health agencies; Medicare Managed
Care Plans and ambulatory surgical
centers. You can stay in the hospital at
no charge and cannot be discharged
before the PRO makes a decision.
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In Other Medicare Health Plans: You
have a right to appeal decisions
concerning your Medicare benefits in the
other Medicare health plans. If you have
any concerns or problems with your plan,
you also have a right to file a grievance
(complaint). You have these rights
regardless of the type of plan in which
you are enrolled. To participate in
Medicare, each health plan must have an
appeal and grievance process for its
members. See the health plan’s
membership materials or contact your
health plan for details about your rights
and how to file a Medicare appeal and
complaint.
You may file an appeal if your health
plan denies a service or terminates or
refuses to pay for services that you
believe should be covered. You may be
eligible for a fast decision (within 72
hours) if you believe that your health or
ability to function could be seriously
harmed by waiting the amount of time
needed for a standard decision. Your
health plan must provide you with written
instructions on how to appeal. The first
step is to contact your plan.
After you file an appeal, the health pan
reviews its original decision to deny you
coverage. Then if your health plan does
not decide in your favor, the appeal
automatically goes to an independent
reviewer that contracts with Medicare.
If you believe you are being discharged
too soon from a hospital, you have a right
to immediate review by the Peer Review
Organization (PRO) in your State. During
the immediate PRO review, you may be
able to stay in the hospital at no charge
and the hospital cannot discharge you
before the PRO reaches a decision.
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From publication No. HCFA 10119
HIPAA Notice of Privacy Practices
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Your Privacy Rights:
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The following is a summary of your rights with respect to your protected health information:
(Please be aware that the Schneider Regional Medical Center can deny your requests in
certain circumstances.)
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You may request a restriction on uses and disclosures of your health information.
You may request that our communications to you be confidential.
You may request to inspect and copy your protected health information ( we may charge a fee for
copying your record.)
You may request an accounting of disclosures of your health information.
You may request an amendment of your protected health information.
You have the right to receive a copy of the complete Notice of Privacy Practices.
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You should also know that if you have greater protections under a specific U.S.
Virgin Island statute or regulations, those protections will continue to apply to you.
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Complaints or Additional Information
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You may file a complaint to us or to the Secretary of Health and Human Services if you believe
that we have violated your privacy rights. You may also request additional information about
this Notice of Privacy Practices.
Write to:
Roy Lester Schneider Hospital
Attention: Patricia Lake-Blyden, Compliance and Privacy Officer
9048 Sugar Estate
St. Thomas, VI 00802
Other Complaint Filing Information:
USVI Department of Health
Commissioner of Health
9048 Sugar Estate, 5th Floor
St. Thomas, U.S.V.I. 00802
PRO Complaint Filing Information:
Peer Review Organization
#1AD Estate Diamond Ruby
PO Box 5989, Sunny Isle
St. Croix, VI 00823
Effective Date: April 14, 2003
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 is a summary notice of your rights. The complete Notice of Privacy Practices is
available at the Registration or Admissions Office.
HIPAA Notice of Privacy Practices
Hospital/Health Center Responsibilities
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Schneider Regional Medical Center is required by law to maintain the privacy
of your protected health information and to give you notice of our duties and
privacy practices. This Notice describes how we may use and disclose your
individually identifiable health information. This Notice also describes your
rights to access and control your health information.
We must follow the terms of this Notice. We reserve the right to change this
Notice consistent with the law. If we change this Notice, we will post a
revised Notice and will make paper copies of the complete Notice available
upon request. The terms of this Notice of Privacy Practices are consistent
with the federal “HIPAA Privacy Regulations”. Any term not defined in this
Notice have the same meaning as it has in the HIPAA Privacy Regulations.
Uses and Disclosures of Your Protected Health Information:
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We are legally permitted, without further notice to or consent from you, to use and / or
disclose your protected health information in the following circumstances.
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We are required by law to disclose health information to the following people:
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For treatment, payment or healthcare operations or to others involved in your care
To other covered entities or for public health activities
To the Food and Drug Administration (FDA)
For Workers’ Compensation or in other legal proceedings
To Coroners, Medical Examiners, Funeral Directors, Organ Donation Agencies
For approved research
For disaster relief programs or health oversight activities
To business associates
For abuse or neglect reporting or as otherwise required by law
Health-related benefit information
To law enforcement personnel or for inmates of prison facilities
Military activity and national security, protective services
Prevention of a serious threat to health or safety
Limited information for a facility directory and to clergy
To You or Your Personal Representative
To the Secretary of the U.S. Department of Health and Human Services upon request
Other uses or disclosures of your health information may be made with your
written authorization.
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Revised 11/04 from RLS & MKS HIPAA Form 1.3 v2 4/14/03
Advance Directives
Living Will and Designation of Health Care Surrogate
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As a patient, you have the right to
formulate Advance Directives and to
make decisions concerning your
medical care, including the right to
accept or refuse medical/surgical
treatment. The Roy Lester Schneider
Hospital is committed to helping
facilitate your expressed wishes
concerning your health care. Our
hospital will honor your directive
within the limits of the law and our
mission, vision, and values. You will
receive the same medical treatment
from Roy Lester Schneider Hospital
whether or not you have signed an
Advance Directive.
Advance
Directives
are
legal
documents that you may complete to
help ensure that your wishes are
carried out when you are unable to
speak for yourself. These documents
indicate your choices regarding
health care decisions, including, but
not
limited
to,
life-prolonging
procedures and the designation of
someone to make health care
decisions in the event you would be
unable to make decisions for
yourself.
Advance Directives are
commonly known as the Living Will
and Designation of a Health Care
Surrogate.
The Living Will is an Advance
Directive Document that allows you
to indicate your choices regarding the
use of life-prolonging procedures.
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According to law, when two
physicians certify that you have either
a terminal condition, end-stage
condition or are in a persistent
vegetative state, your Living Will can
be honored.
Your may also
designate a person to make health
care decisions for you if you become
mentally or physically unable to do so
yourself.
This may be done by
completing a Designation of Health
Care Surrogate document. It is
very important that your wishes
expressed in these documents be
discussed with your physician and
family / significant other.
We would like to request that each
time you come to the hospital to be
admitted as an inpatient that you
bring a copy of your most recently
completed
Advance
Directives.
During your admittance, as an adult
inpatient, you will be asked if you
have
completed
an
Advance
Directive. Your response will be
documented in your medical record.
If you have already signed an
Advance Directive document and
didn’t bring it to the hospital, you will
be asked to complete another.
You may request Advance Directive
forms from the Admitting Department
or designated employee, or your
nurse.