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Office Policies & Procedures

*Please review to be ready to sign at time of initial office visit*

Thank you for choosing Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. for your child’s primary needs. Below you will find a detailed description of our policies and procedures to help you navigate your visit and your family’s primary care experience. You can reach our office at (315) 622-0162.

Appointment Types

Our office hours are 8:30 am to 4:30 pm Monday through Friday with lunch daily from 12:00 pm to 1:15 pm. We do not schedule hours for Saturdays or Sundays, however we may choose to see you in the office based on need.

Annual Well- Exam/ Physical

We encourage all parents /guardians to schedule a complete annual exam at a time when they’re child is physically well. The primary goal of the annual well (physical) is to focus on preventive health care and to discuss measures to ensure your child’s continued wellness. If your child is sick or has health problems please wait to schedule their physical. We may ask you to schedule a follow-up visit at a later date to discuss abnormal results of tests ordered during the exam. We will address these issues during a separate office visit so we have the time to focus on each individual problem. If other issues arise during your child’s physical, you will be responsible for any copays or deductibles at the time of checkout. Please note: Most insurance plans offer only one annual exam yearly (child must be seen the date after the last well exam or after). In the case that you would like your child seen before the annual date a fee will be collected at check in and submitted to your insurance plan for payment. After payment from the insurance plan, we will reimburse you your owed amount from our office (allow up to three months for the claims to process).

Follow-Up Visit

A follow-up visit is intended for managing chronic conditions and discussion of abnormal test results. We recommend regular medical care for the management of chronic conditions such as, but are not limited to, asthma, allergies, diabetes, high cholesterol, obesity, ADHD, anxiety, depression, etc…. Generally, these conditions require careful monitoring and follow-up visits every 3-6 months. We will use these visits to assess your child’s progress, order and evaluate any test, and change or refill your medication. Also, refill requests will not be honored if the child has not been seen in the recommended return visit time.

Urgent/ Sick Visit

An urgent visit is for an acute or new concern. During these visits, we will fully address your child’s acute problem, order necessary tests, and establish a treatment plan. We may ask that you schedule a follow-up visit at a later date to be sure your child has fully recovered and/or to discuss any test results.

Nurse Visit

A nurse visit is for immunization only, weight checks, tuberculin skin test placement and readings or pku screenings. You will see providers for immunization only visits but not for other nurse visits. If you have a question or concern regarding your child please make the front desk staff aware prior to your appointment, so that we can ensure the schedule has flexibility to schedule your child for an urgent/ sick visit.

Check-In Process

A co-pay is the amount of money that is paid to our office by insurer as agreed upon by your insurance. We are unable to waive this payment, as it violates the contract we signed with your insurance company and is solely the patient’s responsibility. Your co-pay is due for any visit in which you see a physician or physician assistant. A deductible is a specific amount charged to the patient by their insurance company. This amount must be paid before the insurance company will pay a claim. It is Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. policy to collect any co-payments, co-insurances and/or deductibles at the time of each visit. (Newborns) If you have just delivered a newborn don’t forget to add your new addition to your insurance policy. Some insurance plans do offer newborn coverage for the first 30-60 days of life. However, we do not abide by those plan benefits. Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. will collect a fee of $200 for all newborns that are not showing on the policy by the first visit.

We accept cash and all major credit cards. All balances are due in full prior to being seen by the providers. If you are unable to pay your balance in full, please contact our office prior to your child’s appointment. If a balance is unpaid after 180 days you may be asked to reschedule your appointment to a later date – and your account may be at risk of being sent to a collections agency.

We encourage you to familiarize yourself with your insurance benefits before your child’s appointment. 

Walk-Ins and Late Arrivals

Rescheduling will be necessary if you are more than 15 minutes late for your appointment. If time allows for late arrivals or walk-ins, we will attempt to fit you in.

Cancellation Policy

Patients must call 24 hours in advance if they are unable to keep their scheduled appointment.  If the appointment is not canceled in advance, the patient will be considered as a no show and will be charged a $35 No Show charge. Fee will be due at time of next visit. Two no shows will be subject to warning of practice dismissal, a third no show will be dismissed from the practice. 

Medical Records

Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. requires an authorization form to be filled out on each patient for the release of each child’s medical records.

In addition, there is a fee of $5.00 for the first 5 pages and .25 per page thereafter and is due when records are copied for the patient.

Labs And Test Results

All lab and test results will be relayed to you within a maximum of two weeks. If you have not heard from us via phone or e-message through the patient portal within this timeframe please call the office. Any result that was faxed to the practice will not be accessible on the portal, i.e. radiology reports. Tests that were ordered by other physicians and providers that are not part of our practice will not be visible on the portal, but still remain a part of your health record.


Messages Left For The Providers

If you need to reach a provider during the business day, please call and leave a message with a member of our front desk staff. All messages will be returned accordingly. Messages that are left during the business day will still be returned after hours. Please remember that the providers are busy during the day with other families. If you feel that your message is of urgency, please schedule an appointment.


Referrals

We will happily refer you to specialists based on your child’s medical conditions. Ideally, this should be done during the office visit when we address that specific concern. If you have not been seen by our providers for this condition, we may ask that you make an appointment with our office before requesting the referral. When calling to request a referral, please be prepared to give us the doctor’s full name, address, telephone number, fax number, specialty, if the specialist is not listed in our system. Please allow five (3) business days for the office to complete your referral request.

Prescription Refills

We encourage our parents/guardians to request refills at their child’s regular appointments. Please do not wait until you are out of medication to call the office for a refill request. Please allow 72 hours (3 business days) for your prescription to be refilled. Controlled Substance Refills – We refill controlled substances for ADHD needs on a monthly basis over the phone with biannual office visits. We refill anti-anxiety/depression medications with 3 month prescriptions once dosing is confirmed helpful, telephone update with new prescription and biannual office visits. as these refills require an office visit. We do e-prescribe all prescriptions please be sure to update pharmacy information on file remember to reconcile your desired pharmacy with the provider or when you checkout


Forms And Letters

Provide the front desk with any forms or letters requiring provider documentation after completing your portion of the form. We are unable to accept responsibility for any forms left at the office without a name and valid date of birth. Please note that some forms may require you to be seen by a provider before completion. In this case you will be asked to schedule an appointment. There is a $10 fee for all forms, letters or charts printed. This fee must be paid prior to form completion or generation of the letter or chart. Please allow five (3-5) business days for the office to complete your form, letter or chart request.

Mailing, Faxing And Emailing

Documents can be mailed via postal mail if a paid self-addressed envelope is provided to Blooming Pediatric & Family Nurse Practitioners, P.L.L.C.. Unfortunately, we do not fax or email documents due to HIPAA.

On-call Service

When the office is closed after hours, weekends, holidays, or inclement weather, we will always have a provider on call. You may reach this provider by calling the main number to the office and then following the prompts to reach the on-call service. Please reserve this service for URGENT medical concerns only. In the event of a medical emergency, call 911. Do not use this service for prescription refills, referrals, lab results, or appointments. These will not be addressed after hours and will have to wait until the following business day. When calling the on-call service, please be sure you provide a working telephone number as our providers will be unable to reach you otherwise.

Emergency Office Closures

In the event of a severe weather emergency it is the responsibility of the patient to check with Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. regarding potential cancellations or appointment rescheduling. Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. will make every attempt to notify patients via the following avenues:

  • Recorded phone message – Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. will attempt to call the patient and leave a message indicated office closure

  • Facebook postings – Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. will post updated information on the Blooming Pediatric Facebook and Instagram pages

Notice of Patients Privacy Rights

Effective Date of this notice: January 1, 2022

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.

Your Rights

You have the right to:

  • Get an electronic or paper copy of your medical record

  • Ask us to correct your medical record

  • Request confidential communications

  • Ask us to limit what we use or share

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

  • Get a copy of this privacy notice

  • Choose someone to act for you

  • File a complaint if you feel your rights are violated


Our Uses and Disclosures

We may use and share your information as we:

  • Treat you

  • Run our organization

  • Bill for your services

  • Help with public health and safety issues

  • Do research

  • Comply with the law

  • Respond to organ and tissue donation requests

  • Work with a medical examiner or funeral director

  • Address workers compensation, law enforcement, and other government requests

  • Respond to lawsuits and legal actions


Your Rights 

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

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

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

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

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

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

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

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. Any corresponding legal documentation must be on file with Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. when care is under anyone other than the patient's biological parents.

File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by calling our clinic and speaking with the privacy officer. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/ We will not retaliate against you for filing a complaint.

Your Choices

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

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

  • Share information with your family, close friends, or others involved in your care

  • Share information in a disaster relief situation


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, and most sharing of psychotherapy notes


Our Uses and Disclosures

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


Treatment. We can use your health information and share it with other professionals who are treating you. A doctor treating you for an injury asks another doctor about your overall health condition.

Payment. We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

Operations. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

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.


Public Health. 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, and Preventing or reducing a serious threat to anyone’s health or safety

Research. We can use or share your information for health research.

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


Organ and tissue donation requests. We can share health information about you with organ procurement organizations.


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


Workers compensation, law enforcement, and other government requests. We can use or share health information about you for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, or special government functions such as military, national security, and presidential protective services. We do not participate in Workers compensation cases or no-fault claims.


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



Our Responsibilities

We 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, in our office, and on our website.

Click Here to download a copy of the Notice of Privacy Practices



Financial Policy

Thank you for choosing Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. as your healthcare provider. We are committed to providing you with the best possible care. Your clear understanding of our Financial Policy is important to our professional relationship. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. Please ask if you have any questions about our fees, financial policy, or your responsibility.

  • All patients must complete our patient information form before seeing a nurse practitioner.

  • Payment is due at time of service unless prior arrangements have been made with our financial department.

  • We accept cash, checks, Visa, MasterCard or Discover.


Insurance Coverage

Your insurance coverage is a contract between you and your insurance company. We are not a party to that contract. If you have insurance, we will help you receive maximum benefits. If we accept your insurance, you must pay any co-payments and/or deductibles allowed at the time of service.

  • In the event we accept assignment of benefits, the patient is still ultimately responsible for all charges. If your insurance company has not paid your account in full within 45 days, the balance is due in full from the patient and/or guarantor.


Usual and Customary Rates

Our practice is committed to providing the best treatment for patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. We file claims as a courtesy to our patients. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, etc., other than to provide factual information as necessary. You are responsible for the timely payment of your account. If you would like to pay out of pocket without insurance please request charges when scheduling desired appointments.


Untimely Payments

In the event of untimely payments, an outside collection agency may and will be utilized to secure payment on all past due accounts.

Insurance Referrals

In the event the patients’ insurance company requires referrals to other physicians or outside tests, your Primary Care Provider must approve those referrals. Please call at least two (2) days in advance of the appointment with another provider because your nurse practitioner may need to evaluate the need of your request with an office visit and some insurance companies request at least 2 days to complete a referral.

Assignment of Insurance Benefits

I request that payment of authorized Medicaid and/or other applicable insurance benefits be made on my behalf to Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. for any services furnished to me by Blooming Pediatric & Family Nurse Practitioners, P.L.L.C.. By signing below, I authorize any holder and its agents to release my medical and/or other necessary information, which may be needed to determine benefits payable for the Healthcare Financing Administration and/or its agents.

Authorization to Release Information

I hereby authorize Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. to furnish any medical records and information necessary to other caregiver offices regarding my child’s illness and treatment.


No Show Policy

I hereby acknowledge Blooming Pediatric & Family Nurse Practitioners, P.L.L.C. charges each patient a set fee of $35.00 every time a scheduled appointment(s) is not canceled 24 hours prior to the appointment.


Newborns

I understand it is my responsibility to ensure that my newborn is promptly added to medical insurance. If my newborn does not have medical insurance by their next visit, I will be responsible for the full balance in full on the date of service and all others following until medical insurance coverage is provided to Blooming Pediatric & Family Nurse Practitioners, P.L.L.C..


Blooming Pediatric & Family Nurse Practitioners, P.L.L.C.

Michal Hovak FNP & Coral Montana PNP

Policies & Procedures Agreement 

Child’s name   ___________________________________


Patient/Parent/Legal Guardian signature   ___________________________________



Staff witness signature   ___________________________________



Date  _____/_____/______