The providers of Creekside Medical understand the patient’s need to have various types of forms completed. We try to be as helpful and sensitive as we can in understanding the urgency of having your forms filled out and signed by the doctor. Because most forms are completed by the provider outside of regular business hours, we require up to 2 weeks to complete each form. Most forms that need to be completed will be provided to you at no additional cost. Please note, at times you will need to be seen by your provider in order for the form to be completed. If you already have an appointment and want your form completed then, please let the scheduler know that you have a form to be completed. This way, we may allot the appropriate time for your office visit.  Forms that are filled out during an office visit will be provided at no additional cost.

From the date the forms are received in our office we will require up to 2 weeks in order to have the forms completed and ready to be picked up by the patient or faxed to the insurance/work facility. We will notify you as soon as they are completed.

In order for us to complete your form, all forms must contain your name, date of birth and any information that needs to be filled out by you. If any forms arrive without the above information, we will be unable to complete the form and this could delay the turnaround time. If you emailed or faxed your form to us, you will receive a confirmation text within 24 hours that your form was received. If you do not receive a confirmation text, please re-send/fax your form.

Please allow the requested time before you call the office to inquire about your form if you have not yet been called to say it is ready to be picked up, faxed or emailed.

If you request that the form be completed sooner than the times listed below, you will need to pre-pay an expedited form fee, in addition to any cost for the original form. Form fees must be paid in advance of them being filled out.

Times and Cost for Forms:

 Sports PEX………………………………………..………… 1 week from date of receipt             No Charge

Medication in School……………………………………….. 1 week from date of receipt             No Charge

Simple Biometric Forms*………………………………….. 1 week from date of receipt              No Charge

Disability Forms*……………………………………………. 2 weeks from date of receipt           $25.00 + Tax

Complex/Work Forms*……………………………………. 2 weeks from date of receipt          $25.00 + Tax

Expedited Form, (In addition to form any form fees)….2 days from receipt of form $20.00 + Tax

*These forms may need to be done during an office visit. We will let you know if you need to schedule an appointment once we have received the form.

Making an Appointment

New patient appointments may be made by calling the office at 360-566-9355. Established patient appointment requests may be made via phone or the patient portal.

If you have not yet chosen a physician, you may wish to read about each of our providers here online. You can review detailed information about any provider on staff, such as educational background and professional training.

Cancelling an Appointment

If you are unable to keep an appointment, please notify the office at least 24 hours in advance so that we can accommodate other patients who need appointments. Appointments cancelled with less than 24 hours’ notice; a $50.00 will be charged. For Same Day appointments, a 3 hours cancellation notice before appointment time should be given to avoid the $50.00 cancellation fee.

Requesting a Prescription Refill

Patients should call their pharmacy unless they need a written prescription. When calling the pharmacy, make sure you are using the right prescription bottle and number, especially if you’ve had a recent change in medication strength or instructions. If in doubt, call the pharmacist to make sure that they select the most recent prescription to refill. The pharmacy will contact the prescribing physician directly to obtain authorization if needed.

Please allow plenty of time when calling your pharmacy for a refill, as it could take up to three business days for your pharmacy to receive authorization from the doctor.  Also, keep in mind that your doctor may want to see you or may require that you complete certain lab tests prior to approving a renewal. This is for your safety.

MEDICATION REFILL INFORMATION

1. For NON CONTROLLED medications, please contact your pharmacy and ask them to contact us. This will speed up the refill process for you as they can communicate with us by fax.
2. For CONTROLLED Medications such as Ritalin, Adderall, Concerta, Dexadrine, or Phentermine of any form, you are required by law to pick up a written prescription at the office. We are not allowed to mail these prescriptions. Please contact us before you are out and allow three (3) business days for us to prepare the prescription.
3. It is your responsibility to notify the office in a timely manner when refills are necessary. You may contact us via phone or thru our patient portal. Approval of your refill may take up to three (3) business days so please be courteous and do not wait until you are out of medication to call.
4. There will be NO early refills of any controlled medications. Please be sure to take your medication as prescribed by your physician.
5. Medication refills will only be addressed during regular office hours. Please notify your provider on the next business day if you find yourself out of medication after hours.
6. Some medications require a prior authorization. Depending on your insurance this process may involve several steps by both your pharmacy and provider. The providers and pharmacies are familiar with the process and will handle the prior authorization as quickly as possible. Your pharmacy is notified of approval status. Please check with them for updates on your request.
7. If you have any questions regarding your medications please discuss these during your appointment. If for any reason you feel your medication needs to be adjusted or changed please contact your provider immediately

Payment for Services

In order for Creekside Medical to continue providing high quality health care, it is important that charges be paid in a prompt manner. Creekside’s payment policy states that payment is due upon receipt of your first statement. Unless covered by insurance, payment can be made in cash, by personal check, or by credit card. There is a charge for checks returned for non-sufficient funds.

Many insurance plans require copays for certain types of services. Full payment of these copays is required before services are rendered. If you have any questions regarding your copays or insurance benefits, please contact your employer’s benefits office.

Insurance Processing

Creekside will prepare and file claims with patients’ insurance companies as a courtesy. Delayed insurance payments do not relieve patients of their obligation to pay balances when due.

To ensure rapid resolution of insurance claims, it is vital that the office has accurate and up-to-date information. It is the patient’s responsibility to supply this information and to keep it current. When any changes occur in your insurance coverage, name, address, or phone number, please immediately inform the patient account representative when you are in the office, telephone the billing office or update your demographics via the patient portal. You also may be asked to update insurance information when you are scheduling an appointment. Periodically you may be asked to provide an updated signature for office files giving consent to bill your insurance.

Fees at Creekside Medical

If you choose to receive services that will not be covered by your insurance plan, (or are not likely to be covered), you may be asked to sign an Advanced Beneficiary Notice (ABN) or a Notice of Patient Financial Responsibility form as an agreement that you are responsible for payment.

If you have any questions concerning your account or about payments, please call our billing office at 360-566-9355.

When patients need a copy of their medical records, Creekside Medical is available to help. Patients may request either printed or electronic copies of their medical records.

PLEASE NOTE: Release of information or medical records requests must comply with state and federal guidelines. Records will not be released without a signed authorization from the patient or the patient’s legal representative.

A person requesting medical records must submit a written consent with the following information:

• Patient name, date of birth, contact information and last four digits of your SSN
• Information being requested and dates of service
• The name and address of the person the information is being released to

Requests will be processed within 30 working days of receipt of the signed authorization. All records requested may be picked up in person at the office by the patient requesting the records, mailed to the patient or faxed to a physician. Valid photo ID is required to pick up medical records. Duplication or copy fees may be assessed. Any fees charged will need to be paid in full prior to  records being released.

Duplication Fees:

Patients and non-patient requestors will be charged clerical and copy fees according to WAC 70.02.0800 plus any applicable sales tax.

• If your child is younger than 3 months with a rectal temperature >100.4ºF
• If your child has a very high fever (>104ºF)
• If your child is inconsolable despite giving an adequate dose of a fever reducer

• If your child has a fever >104ºF after the immunization
• If the immunization site is very swollen, greater than 3 inches in size, or has a red streak running from the injection site

• If your child is unable to keep liquids down for several hours (6 hours for infants or 12 hours for older children).
• If your child is having severe pain in his/her stomach with vomiting.
• If the vomit has blood or is green in color.
• If your child is appears very dehydrated (sunken eyes, not urinating for > 8 hours if your child is less than 1 year old, or greater than 12 hours if your child is greater than 1 year old).

• If your child is having bloody stools.
• If your child has become very dehydrated (sunken eyes, not urinating for > 8 hours if your child is less than 1 year old, or greater than 12 hours if your child is greater than 1 year old).

• If your child is having trouble breathing or is breathing rapidly.
• If your child has asthma or reactive airway disease and his/her breathing is not responding  to breathing treatments given every four hours

• If your child’s sore throat includes other symptoms: excessive drooling, severe difficulty swallowing, difficulty breathing, or being unable to open his/her mouth fully.
• If your child’s earache includes other symptoms: stiff neck, loss of balance when walking, or redness and swelling behind one ear in comparison to the other ear.

• If your child is inconsolable or unresponsive or with a high fever (>104ºF) and also has a new rash. This situation is considered an emergency. We recommend that your child be seen immediately in an emergency room.
• If the rash is purple/blood-colored spots, or bright red and tender to touch, or red streaks that are spreading, or appears like a burn.
• If the rash is associated with swollen lips, swollen tongue, difficulty breathing, or abdominal pain, go to the emergency room as this may be a severe allergic reaction.

• If your child sustained trauma to the eye.
• If your child is unable to see from the eye or complaining of severe pain.
• If your child cannot open his/her eye because of eyelid swelling. Wipe away any discharge with a warm washcloth to help the eye open.

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.

If you have any questions about this Notice please contact
our Privacy Officer, Michelle Vincent

This Notice of Privacy Practices describes how we 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 or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who is involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.

Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment:We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, wewill have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories:Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.

Others Involved in Your Health Care or Payment for your Care:Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

2. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information.This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by submitting in writing to our Privacy Officer ; send the request to Creekside Medical, Attn: Privacy Officer 2501 NE 134^thStreet, Ste 200 Vancouver, WA 98686.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer and send the request to Creekside Medical, Attn: Privacy Officer 2501 NE 134^thStreet, Ste 200 Vancouver, WA 98686.

You may have the right to have your physician amend your protected health information.This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3. 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 Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

You may contact our Privacy Officer, Michelle Vincent at (360)566-9355 or mvincent@creeksidemed.com for further information about the complaint process.

This notice was published and becomes effective on 3-18-2013.

As a Creekside Medical Patient, it is Your Right:

1. To receive care that respects your values and beliefs and promotes your dignity, personal privacy, and safety.
2. To receive care that is free from all forms of discrimination, abuse, or neglect.
3. To have us communicate with you in a way that you understand.
4. To know the names of physicians, nurses, and others involved in your care.
5. To receive the information you need to make informed choices about treatment, to be involved in planning your care, and to request, accept or refuse treatment.
6. To involve persons of your choice in your care.
7. To know the immediate and long-term financial implications of treatment options, insofar as they are known. You have the right to be informed of charges for services as well as payment options.
8. To expect that efforts will be made to provide you continuous, coordinated, and appropriate care.
9. To receive honest and clear information about your health status, your diagnosis, treatment options, and prognosis. You are entitled to the opportunity to discuss specific procedures and/or treatments, the risks involved the length of recuperation, and the medically reasonable alternatives and their accompanying risks and benefits.
10. To expect that your treatment preferences will be responded to, as delineated in your Advance Directive.

11. To have personal and medical information protected as described in Advocate’s Notice of Privacy Practices.
12. To know when information about you must be shared with others.
13. To access financial services to explain your charges, your bill, and your options for payments or other financial arrangements if necessary if needed.
14. To share concerns or complaints about your care and receive a prompt response.

It is Your Responsibility as a Creekside Medical Patient:

1. To provide correct personal and family health information.
2. To follow the plan for your care.
3. To ask questions if you do not understand what we tell you.
4. To maintain appointments as scheduled, or to reschedule in a timely fashion.
5. To recognize the impact of your lifestyle on your personal health.
6. To be respectful of others’ dignity, privacy, and safety.
7. To accept financial responsibility for health care services and to work cooperatively with the office to resolve financial obligations.

You’ll notice that if you call our answering service after hours, they will first help you connect to the advice nurse line available through your insurance company.  We know it can be frustrating to have to make multiple phone calls when you are worried, so we wanted to be sure you had the phone numbers to your particular insurance’s advice nurse line.   They are listed below, so put them on your fridge or in your cell phone, and please give them a call before you call our answering service.  If that advice nurse recommends that you talk to our on call physician or nurse practitioner, then call the office and our answering service can page our on call provider.

Molina
1-888-275-8750

Cigna
1-800-244-6224

Pacficsource
1-855-834-6150

Regence
1-800-267-6729

Aetna
1-800-556-1555

UHC
1-877-365-7949

Providence
1-800-700-0481