Robert R Artwohl, MD, PC • 3300 Providence Drive, Suite 309 • Anchorage AK 9950 • Phone: 907-222-6240 • Fax: 907-222-6870
INSTRUCTIONS FOR NEW PATIENTS
Welcome to the Alaska Vein Clinic! Were looking forward to helping you.
Below we’ve listed four steps to make your first visit go as smoothly as possible.
Fill out the online vein & medical questionnaire and patient registration forms.
Medical and Vein Questionnaire
Patient Registration Form
Area(s) of Concern
If you like, you can download the leg diagram form below and use it in one of the three ways.
1. Mark your areas of concern with the application you used to open it, save and download it into the form as .pdf or Word (.docx) file.
2. Print it out, mark it, then scan or photograph it and upload the image to the form.
3. Same as choice 2, except just bring it with you at the time of your appointment.
Read and Acknowledge Privacy Practices and Financial Policies:
AVC Privacy Practices
Your Rights Regarding Your Health Information
You are entitled to:
Get a copy of health and claims records
- You can ask to see or get a copy of your health and claims records 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 and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
- You can ask us to correct your health and claims records if you think they are 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 consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not.
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.
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 complain if you feel we have violated your rights by contacting us using the information on page 1.
- 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 hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices of Health Information:
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 payment for your care
- Share information in a disaster relief situation
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
Our Use and Disclosures of Your Health Information
We typically use or share your health information in the following ways.
Help manage the health care treatment you receive
We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
- We can use and disclose your information to run our organization and contact you when necessary.
- We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health services
We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan
We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
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. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
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
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 and work with a medical examiner or funeral director
- We can share health information about you with organ procurement organizations.
- 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.
- 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 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.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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, on our web site, and we will mail a copy to you.
Effective Date: 10/9/2014
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
AVC Financial Policy
PAYMENT FOR OFFICE VISITS:
Charges for your care or the care of a dependent are your responsibility. We will normally bill your insurance for office visits and any necessary surgery. Please bring proof of insurance to the office with you. It is your responsibility to provide us with up-to-date insurance information for our billing staff. If you do not have insurance coverage at the time of service, please discuss payment arrangements with the office staff. We will be happy to work out a reasonable and regular payment schedule we both find acceptable.
Your insurance coverage is a contract between you and your insurance company. You should be aware of the terms of your coverage with them. Due to the number of different insurance companies and their policies, it is difficult to keep track of policies. However, we will obtain preauthorization for any procedure that requires it.
Deductible: If you have not met your insurance deductible, please inform the office staff.
Medicaid: We accept Medicaid. Medicaid coupon is required.
Medicare Part B: We accept Medicare. Please provide us with proof of insurance.
Tricare: Dr. Artwohl is a preferred provider with Tricare.
Veterans Administration: Dr. Artwohl is proud to treat our veterans and is often referred patients from the VA. If your health care coverage is through the VA, in most cases you must be referred from the VA Clinic system.
Private and Government Contracted Private Insurance Companies: Dr. Artwohl is a preferred provider for most insurance carriers in Alaska. We will obtain prior authorization for any procedure that is required by your insurance company. We will file an insurance claim on your behalf. Prior authorization is not an absolute guarantee of payment. Ultimately you are responsible for your bill.
HOW WE BILL
1) If you are having surgery, we will bill your insurance company. We do not ask for any upfront payments for insured patients.
2) Once we have received an explanation of benefits from your insurance company, you will be sent a statement from this office.
3) At that time full payment of the balance, if any, will be due upon receipt. However, if you find it is necessary, we can work out a reasonable and regular payment schedule we both find acceptable. You will be expected to notify this office and arrangements can be made at that time.
If you are uninsured, we will have worked out a payment schedule with you, but we will ask for partial payment upfront.
When you come in for an appointment, we make every effort for you to be seen at that time, but occasionally situations arise that prevent this. We ask for your patience when this occurs. If there is an unusual delay, our staff will advise you. If you are unable to wait, we will gladly reschedule your appointment for a later time.
Canceling an Appointment: Should you find it necessary to cancel or reschedule an appointment, please advise us as soon as possible. We often have patients on call lists who would like to get to see us soon if something opens up.
ACKNOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICIES
Bring in the following items with you:
1. Photo ID
2. Insurance Cards
3. Medication list
4. Records of prior venous procedures done elsewhere, if available.
Please read the Coronavirus Precautions
1. Unless it would present a severe hardship or the patient requires a guardian, only the patient should come to the office. Anyone accompanying the patient should wait in the car or the main lobby of the hospital.
2. All patients should wear a face mask. Please bring a freshly washed face mask from home. If you cannot supply your own, we have a limited supply and will be provided one as long as supplies last.
3. All patients should sanitize their hands upon entering the office.
4. No one should come to the office who has a fever, cough, fatigue, loss of appetite, loss of appetite or smell, or body aches.
5. No one should come to the office within two weeks after exposure to someone with a Coronavirus infection.
6. No one should come to the office who has traveled outside of Alaska within two weeks of their appointment.
Area(s) of Concern
If you like, you can download the leg diagram form below and use it in one of the three ways.
1. Mark your areas of concern with the application you used to open it, save and download it into the AVC Vein and Medical Questionnaire form as .pdf or Word (.docx) file.
2. Print out the diagram, mark it, then scan or photograph it and upload the image to the AVC Vein and Medical Questionnaire form.
3. Same as choice 2, except just bring it with you at the time of your appointment and we’ll scan it to your chart.
Alaska Vein Clinic • 3300 Providence Drive, Suite 309 • Anchorage, AK 99508
Phone: 907-222-6240 • Fax: 907: 907-222-6870
This website was created and is maintained by the Alaska Vein Clinic.