Patient intake form

I voluntarily consent to medical care, evaluation, testing, and treatment provided by Kidney Hypertension Clinic and its physicians, advanced practice providers, and clinical staff, as they determine to be medically appropriate for my kidney and blood pressure care. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me about the results of any examination or treatment.

I authorize Kidney Hypertension Clinic to contact me by phone, text message, email, patient portal, and mail regarding my care, including appointment reminders, test results, treatment, and billing. These are not marketing messages. Message and data rates may apply, and I may opt out of text messages at any time by replying STOP. I authorize the practice to leave messages containing the minimum necessary information at the phone numbers and addresses I provide.

I authorize Kidney Hypertension Clinic to share information about my care, to the extent necessary, with the family members, friends, or personal representatives I have listed as my emergency or health-information contacts.

We do our best to schedule appointments in a timely manner and reserve dedicated time for each patient. If you need to cancel or reschedule, please notify our office more than 24 hours before your scheduled appointment time. Appointments that are missed, cancelled with less than 24 hours' notice, or unable to be completed due to late arrival may be considered a late cancellation or no-show. A $50 fee may be charged for late cancellations and no-show appointments.

We make every effort to see patients at their scheduled time. To help our office stay on schedule, new patients should arrive 30 minutes before their appointment and established patients should arrive 15 minutes before. If you arrive late, your appointment may need to be rescheduled. If your provider is still able to see you, your visit will be treated as a work-in appointment and you will be seen when the schedule allows, so that other patients with scheduled appointments are seen on time. If you arrive late and we are unable to see you, the missed appointment will be considered a late cancellation and subject to our $50 fee.

To help us maintain an accurate and complete medical record, we ask that you provide our office with updated information at every visit. This includes any changes to your name, address, phone number, insurance coverage, health status, medications, and any medical care or services you have received from other providers.

Kidney Hypertension Clinic uses a patient portal to improve communication and give patients convenient access to their health information. During your visit, our staff will help ensure that you have access to the portal.

Through the patient portal, you may contact your doctor's medical assistant with health questions or medication refill requests. You may also view your visit summary and lab results from testing performed in our office.

We file claims with most insurance companies as a courtesy. Patients are responsible for paying all required amounts at the time of service, which may include copays, deductibles, coinsurance, outstanding balances, or the full visit charge for patients without insurance. If you have an outstanding balance, our staff may notify you before your appointment, and payment may be required before services are provided. Patients are ultimately responsible for understanding their insurance benefits and payment obligations. Please contact our billing department before your appointment with any questions about what you may owe. We accept cash, checks, and credit cards (MasterCard, Visa, Discover, and American Express). Referral requirements are described in the next section.

Some insurance plans, including HMO, PPO, and POS plans, may require a written referral before you can be seen by our office. If your insurance plan requires a referral, it must be obtained before your appointment.

Referral requirements are determined by your insurance policy. While our office may assist when possible, the patient is ultimately responsible for ensuring that a valid referral is on file before being seen. If you are seen without the required referral, you may be responsible for the full cost of the visit.

It is also the patient's responsibility to notify our office of any changes to insurance coverage, including termination of coverage, change of plan, policy number, group number, or policyholder information.

Patients with Medicare who do not have supplemental insurance are responsible for the 20 percent portion that Medicare does not cover. This amount is due at the time of service.

All copays, deductibles, coinsurance, and any other required payments are due at the time of service. If payment is not made at the time of service, our office may refuse to provide non-emergency services. These payment requirements are part of your insurance policy and patient financial responsibility.

To help us manage your medications safely and accurately, we require that you bring all of your current medications to each appointment. This includes prescription medications, over-the-counter medications, vitamins, supplements, and any medications prescribed by other providers.

All full medication refills require an appointment with one of our providers. Refills cannot be completed by phone request alone.

In order for any refill to be considered, the patient must have completed labs within the last 6 months. If labs are not up to date, the patient may be required to complete lab work before medication refills can be approved.

At your appointment, your provider will review your medications, labs, and treatment plan. When medically appropriate, your provider will send enough refills to last until your next scheduled appointment.

Emergency refills may be considered as a one-time exception for a 5-day supply only. Emergency refills still require that the patient has completed labs within the last 6 months. This exception is limited to one time per medication and remains subject to provider review and approval.

Controlled medications will only be refilled during an appointment. No exceptions can be made.

Some medications require prior authorization from your insurance company before they can be filled. If your medication requires a new or renewed prior authorization, your refill may be delayed. Please understand that our office does not control the timing of insurance approvals.

To better support our patients, Kidney Hypertension Clinic has partnered with Nephron Pharmacy, located at our Lawrenceville office. This is an optional benefit and patients are not required to use Nephron Pharmacy. If Nephron Pharmacy is notified in advance, they may be able to have your medications ready for pickup at checkout after your appointment, as long as your provider determines that continuing the medication is medically appropriate.

If you need an FMLA form completed, please allow up to 10 business days for processing.

Due to the time and detail required to complete these forms, there is a $25 form completion fee. This fee must be paid before the form can be completed.

Please note that Kidney Hypertension Clinic, PC does not complete long-term disability forms.

If you are due a refund on your account and have not received payment in a timely manner, please contact our billing department so we can confirm that your account has been reviewed and posted correctly. You can email Billing@khcpc.com or call (770) 962-1231 and ask to speak to our billing department.

I hereby authorize payment of insurance benefits directly to Kidney Hypertension Clinic and its physicians for services provided to me. This authorization includes basic benefits, major medical benefits, and any other benefits otherwise payable to me, up to the regular charges for the treatment or services rendered.

I understand that I am financially responsible for all charges for services provided by Kidney Hypertension Clinic and its physicians, including any amounts not paid by my insurance company.

A finance charge may be applied to any outstanding unpaid balance after 30 days at a rate of 18% per year.

At Kidney Hypertension Clinic, we are committed to providing high-quality, compassionate care at every level of our practice. Our medical team includes board-certified nephrologists, advanced practice providers, and certified medical assistants who work together to support your kidney and blood pressure health.

Our advanced practice provider team includes nurse practitioners and physician assistants. Each provider has completed advanced medical training and holds a graduate degree in nursing or physician assistant studies. These providers are licensed to perform physical examinations, evaluate medical concerns, prescribe medications, create treatment plans, and provide patient education and counseling.

Our advanced practice providers work closely with our physicians to make sure each patient receives appropriate, timely care. They are trained to recognize when a patient needs additional evaluation from a supervising physician or another specialist.

As a patient at Kidney Hypertension Clinic, you may be scheduled with an advanced practice provider for the following types of visits:

• Hospital follow-up appointments
• Routine follow-up visits
• Nephrology education visits

For follow-up care, Kidney Hypertension Clinic may schedule patients to alternate visits between a physician and an advanced practice provider. For example, after your visit with a physician, your next follow-up appointment may be scheduled with a member of our advanced practice provider team.

You are in excellent hands with the medical team at Kidney Hypertension Clinic.

I authorize Kidney Hypertension Clinic to release copies of my medical records, including current and prior records, to other healthcare providers, practices, hospitals, clinics, or other medical facilities involved in my care.

This authorization includes permission to release medical information that may relate to alcohol or drug use, psychiatric or psychological care, pregnancy, sexually transmitted diseases, HIV testing, AIDS, AIDS-related conditions, and any other information contained in my medical record.

This authorization is voluntary and will remain in effect until I revoke it. I understand that I may revoke this authorization at any time by submitting a written request to Kidney Hypertension Clinic, except to the extent that the practice has already acted in reliance on it. I understand that information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law.

I understand and agree that a copy, electronic copy, or faxed copy of this authorization shall be considered as valid as the original.

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.

How we may use and disclose your health information

Without your written authorization, we may use and disclose your protected health information (PHI) for treatment (providing and coordinating your care, and sharing information with other providers, hospitals, labs, and pharmacies involved in your care), payment (billing and obtaining payment, verifying coverage, and obtaining prior authorizations), and health care operations (the business activities of running our practice, such as quality assessment and staff training).

Unless you object, we may share relevant information with a family member, friend, or other person you involve in your care or payment. We may contact you with appointment reminders, test results, and information about treatment alternatives or health-related benefits. We may also disclose PHI as required or permitted by law (for example, for public-health activities, court orders or subpoenas, law enforcement, or to report suspected abuse or neglect).

Business associates

We may share PHI with "business associates" who perform services for us (such as billing, electronic health records, and secure data hosting). Each is required by written agreement to safeguard your information.

Your rights

You have the right to: request restrictions on certain uses and disclosures; request confidential communications by alternative means or locations; inspect and obtain a copy of your records; request an amendment to your records; receive an accounting of certain disclosures; receive a paper copy of this Notice; and be notified following a breach of unsecured PHI. Uses and disclosures not described in this Notice will be made only with your written authorization, which you may revoke.

We are required by law to protect your PHI and to follow the terms of the Notice currently in effect. We reserve the right to change this Notice; revisions will be posted in our offices and on our website. To exercise your rights or file a complaint, contact our Privacy Officer at Kidney Hypertension Clinic, 605 Old Norcross Rd, Lawrenceville, GA 30046. You may also complain to the U.S. Department of Health & Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

Acknowledgement: I acknowledge that I have been provided with, and have had the opportunity to review, this Notice of Privacy Practices.

I voluntarily consent to medical care, evaluation, testing, and treatment provided by Kidney Hypertension Clinic and its physicians, advanced practice providers, and clinical staff, as they determine to be medically appropriate for my kidney and blood pressure care. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me about the results of any examination or treatment.

I authorize Kidney Hypertension Clinic to contact me by phone, text message, email, patient portal, and mail regarding my care, including appointment reminders, test results, treatment, and billing. These are not marketing messages. Message and data rates may apply, and I may opt out of text messages at any time by replying STOP. I authorize the practice to leave messages containing the minimum necessary information at the phone numbers and addresses I provide.

I authorize Kidney Hypertension Clinic to share information about my care, to the extent necessary, with the family members, friends, or personal representatives I have listed as my emergency or health-information contacts.

We do our best to schedule appointments in a timely manner and reserve dedicated time for each patient. If you need to cancel or reschedule, please notify our office more than 24 hours before your scheduled appointment time. Appointments that are missed, cancelled with less than 24 hours' notice, or unable to be completed due to late arrival may be considered a late cancellation or no-show. A $50 fee may be charged for late cancellations and no-show appointments.

We make every effort to see patients at their scheduled time. To help our office stay on schedule, new patients should arrive 30 minutes before their appointment and established patients should arrive 15 minutes before. If you arrive late, your appointment may need to be rescheduled. If your provider is still able to see you, your visit will be treated as a work-in appointment and you will be seen when the schedule allows, so that other patients with scheduled appointments are seen on time. If you arrive late and we are unable to see you, the missed appointment will be considered a late cancellation and subject to our $50 fee.

To help us maintain an accurate and complete medical record, we ask that you provide our office with updated information at every visit. This includes any changes to your name, address, phone number, insurance coverage, health status, medications, and any medical care or services you have received from other providers.

Kidney Hypertension Clinic uses a patient portal to improve communication and give patients convenient access to their health information. During your visit, our staff will help ensure that you have access to the portal.

Through the patient portal, you may contact your doctor's medical assistant with health questions or medication refill requests. You may also view your visit summary and lab results from testing performed in our office.

We file claims with most insurance companies as a courtesy. Patients are responsible for paying all required amounts at the time of service, which may include copays, deductibles, coinsurance, outstanding balances, or the full visit charge for patients without insurance. If you have an outstanding balance, our staff may notify you before your appointment, and payment may be required before services are provided. Patients are ultimately responsible for understanding their insurance benefits and payment obligations. Please contact our billing department before your appointment with any questions about what you may owe. We accept cash, checks, and credit cards (MasterCard, Visa, Discover, and American Express). Referral requirements are described in the next section.

Some insurance plans, including HMO, PPO, and POS plans, may require a written referral before you can be seen by our office. If your insurance plan requires a referral, it must be obtained before your appointment.

Referral requirements are determined by your insurance policy. While our office may assist when possible, the patient is ultimately responsible for ensuring that a valid referral is on file before being seen. If you are seen without the required referral, you may be responsible for the full cost of the visit.

It is also the patient's responsibility to notify our office of any changes to insurance coverage, including termination of coverage, change of plan, policy number, group number, or policyholder information.

Patients with Medicare who do not have supplemental insurance are responsible for the 20 percent portion that Medicare does not cover. This amount is due at the time of service.

All copays, deductibles, coinsurance, and any other required payments are due at the time of service. If payment is not made at the time of service, our office may refuse to provide non-emergency services. These payment requirements are part of your insurance policy and patient financial responsibility.

To help us manage your medications safely and accurately, we require that you bring all of your current medications to each appointment. This includes prescription medications, over-the-counter medications, vitamins, supplements, and any medications prescribed by other providers.

All full medication refills require an appointment with one of our providers. Refills cannot be completed by phone request alone.

In order for any refill to be considered, the patient must have completed labs within the last 6 months. If labs are not up to date, the patient may be required to complete lab work before medication refills can be approved.

At your appointment, your provider will review your medications, labs, and treatment plan. When medically appropriate, your provider will send enough refills to last until your next scheduled appointment.

Emergency refills may be considered as a one-time exception for a 5-day supply only. Emergency refills still require that the patient has completed labs within the last 6 months. This exception is limited to one time per medication and remains subject to provider review and approval.

Controlled medications will only be refilled during an appointment. No exceptions can be made.

Some medications require prior authorization from your insurance company before they can be filled. If your medication requires a new or renewed prior authorization, your refill may be delayed. Please understand that our office does not control the timing of insurance approvals.

To better support our patients, Kidney Hypertension Clinic has partnered with Nephron Pharmacy, located at our Lawrenceville office. This is an optional benefit and patients are not required to use Nephron Pharmacy. If Nephron Pharmacy is notified in advance, they may be able to have your medications ready for pickup at checkout after your appointment, as long as your provider determines that continuing the medication is medically appropriate.

If you need an FMLA form completed, please allow up to 10 business days for processing.

Due to the time and detail required to complete these forms, there is a $25 form completion fee. This fee must be paid before the form can be completed.

Please note that Kidney Hypertension Clinic, PC does not complete long-term disability forms.

If you are due a refund on your account and have not received payment in a timely manner, please contact our billing department so we can confirm that your account has been reviewed and posted correctly. You can email Billing@khcpc.com or call (770) 962-1231 and ask to speak to our billing department.

I hereby authorize payment of insurance benefits directly to Kidney Hypertension Clinic and its physicians for services provided to me. This authorization includes basic benefits, major medical benefits, and any other benefits otherwise payable to me, up to the regular charges for the treatment or services rendered.

I understand that I am financially responsible for all charges for services provided by Kidney Hypertension Clinic and its physicians, including any amounts not paid by my insurance company.

A finance charge may be applied to any outstanding unpaid balance after 30 days at a rate of 18% per year.

At Kidney Hypertension Clinic, we are committed to providing high-quality, compassionate care at every level of our practice. Our medical team includes board-certified nephrologists, advanced practice providers, and certified medical assistants who work together to support your kidney and blood pressure health.

Our advanced practice provider team includes nurse practitioners and physician assistants. Each provider has completed advanced medical training and holds a graduate degree in nursing or physician assistant studies. These providers are licensed to perform physical examinations, evaluate medical concerns, prescribe medications, create treatment plans, and provide patient education and counseling.

Our advanced practice providers work closely with our physicians to make sure each patient receives appropriate, timely care. They are trained to recognize when a patient needs additional evaluation from a supervising physician or another specialist.

As a patient at Kidney Hypertension Clinic, you may be scheduled with an advanced practice provider for the following types of visits:

• Hospital follow-up appointments
• Routine follow-up visits
• Nephrology education visits

For follow-up care, Kidney Hypertension Clinic may schedule patients to alternate visits between a physician and an advanced practice provider. For example, after your visit with a physician, your next follow-up appointment may be scheduled with a member of our advanced practice provider team.

You are in excellent hands with the medical team at Kidney Hypertension Clinic.

I authorize Kidney Hypertension Clinic to release copies of my medical records, including current and prior records, to other healthcare providers, practices, hospitals, clinics, or other medical facilities involved in my care.

This authorization includes permission to release medical information that may relate to alcohol or drug use, psychiatric or psychological care, pregnancy, sexually transmitted diseases, HIV testing, AIDS, AIDS-related conditions, and any other information contained in my medical record.

This authorization is voluntary and will remain in effect until I revoke it. I understand that I may revoke this authorization at any time by submitting a written request to Kidney Hypertension Clinic, except to the extent that the practice has already acted in reliance on it. I understand that information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law.

I understand and agree that a copy, electronic copy, or faxed copy of this authorization shall be considered as valid as the original.

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.

How we may use and disclose your health information

Without your written authorization, we may use and disclose your protected health information (PHI) for treatment (providing and coordinating your care, and sharing information with other providers, hospitals, labs, and pharmacies involved in your care), payment (billing and obtaining payment, verifying coverage, and obtaining prior authorizations), and health care operations (the business activities of running our practice, such as quality assessment and staff training).

Unless you object, we may share relevant information with a family member, friend, or other person you involve in your care or payment. We may contact you with appointment reminders, test results, and information about treatment alternatives or health-related benefits. We may also disclose PHI as required or permitted by law (for example, for public-health activities, court orders or subpoenas, law enforcement, or to report suspected abuse or neglect).

Business associates

We may share PHI with "business associates" who perform services for us (such as billing, electronic health records, and secure data hosting). Each is required by written agreement to safeguard your information.

Your rights

You have the right to: request restrictions on certain uses and disclosures; request confidential communications by alternative means or locations; inspect and obtain a copy of your records; request an amendment to your records; receive an accounting of certain disclosures; receive a paper copy of this Notice; and be notified following a breach of unsecured PHI. Uses and disclosures not described in this Notice will be made only with your written authorization, which you may revoke.

We are required by law to protect your PHI and to follow the terms of the Notice currently in effect. We reserve the right to change this Notice; revisions will be posted in our offices and on our website. To exercise your rights or file a complaint, contact our Privacy Officer at Kidney Hypertension Clinic, 605 Old Norcross Rd, Lawrenceville, GA 30046. You may also complain to the U.S. Department of Health & Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

Acknowledgement: I acknowledge that I have been provided with, and have had the opportunity to review, this Notice of Privacy Practices.