Effective Date: 1/1/2025
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YOUR HEALTH AND WELL-BEING ARE OF UTMOST IMPORTANT TO US. IF YOU ARE DEALING WITH ANY TYPE OF EMERGENCY ALWAYS CALL 911 AND GO TO THE NEAREST EMERGENCY ROOM. ONCE YOU HAVE BEEN STABILIZED HAVE THE ER DOCTOR REACH OUT TO US AT 281-565-1009.
NOTICE OF PRIVACY PRACTICES
Notice of Privacy Practices (hereinafter referred to as The Notice): You have the right to read The Notice before you decide whether to sign this consent. It provides a description of our treatment, payment activities, and healthcare operations, the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. The Notice is posted on the wall and a copy is also available at the front desk. We encourage you to read it carefully and completely before signing consent.
We reserve the right to change The Notice as described in our Notice of Privacy practices. If we change our privacy practices, we will issue a revised notice of privacy practices which will contain changes. Those changes may apply to any of our protected health information that we maintain. You may obtain a copy of The Notice, including any revisions at any time by contacting:
Contact person: Office Manager, Colon Liver Gastro Consultants PLLC
Address: 16651 Southwest Freeway, Ste 370, Sugar Land, TX 77479
Telephone: 281-565-1009
Right to revoke: You will have the right to revoke the consents signed in here at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received revocation request, and that we may decline to treat you or to continue treating you if you revoke this or other consents except in emergencies for a period not to exceed four weeks.
CONSENT TO CALL
By signing this form, the patient gives permission for the practice to use the information provided as part of the registration or check-in process to text, email and call the patient on their home and/or cellphone on all matters including but not limited to medical and billing matters. This includes: Entry of any telephone contact number constitutes written consent to receive any automated, prerecorded, and artificial voice telephone calls initiated by the Practice. To alter or revoke this consent, visit the Athena Patient Portal “Contact Preferences”. In order to register for the patient portal, the patient will provide the practice with a verifiable email address.
COMMUNICATION POLICIES
We are committed to maintaining efficient and effective communication with our patients. Understanding that there are various circumstances requiring different levels of urgency and attention, we have established the following communication policies to ensure clarity and prompt response.
General Communication
1. Telephone Communication: While we endeavor to answer calls promptly in real time, it is not always possible to do so without making you wait for long periods of time until staff become available. We recommend leaving a voicemail on our system at 832-621-3334, or utilizing our messaging service. This approach ensures accountability, proper documentation, and minimizes the risk of miscommunication. Please be advised that our response time can be up to 72 hours. Our messaging system is not for immediate response; therefore, for urgent medical needs or emergencies, it should not be used.
2. Emergencies and Post-Procedure Complications and Pain: In the event of an emergency or if you experience significant pain following a procedure, it is crucial to call 911 and visit the nearest emergency room immediately. Once your condition is stable, please have the ER doctor contact us for coordination of your care.
Specific Requests
1. Routine Inquiries: For routine inquiries, such as lab results or medication refill requests, we ask that you schedule a tele-visit with one of our providers. Please note that the provider may not be able to promptly respond to messages sent through the patient portal or other channels until the scheduled tele-visit or in-office visit.
2. Scheduling Routine Office Appointments: To schedule a routine office appointment, please contact our office directly or visit our website at www.houstoncolonoscopy.com and choose the appointment request option. For after-hours requests, you may call 832- 621-3334. We aim to respond within 72 hours and schedule your appointment at the earliest convenience.
Athena Portal Usage
1. Non-Emergency Communication: Patients are advised not to send messages regarding emergencies through the Athena portal. While this method is available for non-urgent communications, we are not liable for any delays in response or lapses in healthcare due to the use of this portal. This policy is in place to ensure patient safety and timely management of healthcare needs.
COMPLIANCE & DISCLOSURE STATEMENTS AS PER TEXAS OCCUPATION CODE- SECTION 102.006
In line with Section 102.006 of the Texas Occupations Code, this statement is to acknowledge that I have been fully informed and have made a personal choice regarding my doctors and healthcare facility. This choice is based on the quality and safety of care, patient satisfaction history, and my own knowledge and understanding.
In exercising my rights concerning in-network or out-of-network coverage and cost sharing, my attending doctor(s) and/or the clinic (facility) have provided the following disclosures:
1. Affiliations Disclosure: At the initial contact and at the time of referral, any affiliations the referring doctor or facility may have with other healthcare providers or facilities were disclosed to me. This is in the interest of maintaining transparency regarding the quality and safety of my healthcare.
2. Remuneration Disclosure: It has been disclosed that my doctor(s) and/or clinic (facility) may receive direct or indirect remuneration for referring me to specific providers or facilities. This disclosure is made as part of exercising my right to choose my healthcare provider(s) and facility under my health plan, in compliance with all relevant federal and state laws, including Medicare, ERISA, PPACA, and Section 102.006 of the Texas Occupations Code.
The following are the doctors or facilities with noted affiliations and potential for remuneration: Methodist Hospital, Memorial Hermann Surgery Center, Sugar Land Surgery Center, Gastroenterology Center, Cosmopolitan Surgical PLLC.
This statement serves as an acknowledgment of my informed decision-making in the selection of healthcare services, upholding my rights to quality and safety in healthcare choices.
HEALTHCARE SERVICES AND PATIENT RESPONSIBILITIES
Please note that these guidelines are in place to ensure a smooth healthcare experience. We appreciate your understanding and cooperation.
Referrals: For HMO insurance holders, you agree to obtain a referral from your Primary Care Physician (PCP) before visiting our specialists. The referral should include your demographic details, referral reason, coverage dates, visit authorization number, and insurance referral number. Without a valid referral, self-pay rates will apply. You agree to complete all treatments within the referral’s validity.
Procedure Results: Familiarize yourself with the procedures we offer by reading the informed consent documents, which detail the advantages, disadvantages, potential risks and alternatives. If you have questions or concerns, please ask before signing or scheduling the procedures. You have the option not to undergo a procedure.
Labs and Imaging: Choose your preferred labs and imaging centers. We provide some lab tests but cannot offer all in-house. Lab orders will be provided in print; if lost, we can mail them to you. • Verify with your insurance which labs are covered. Uncovered lab services may result in direct billing to you. Labs and imaging should be done promptly after receiving orders. • Results from labs take about a week to reach us and be posted to your chart.
Ensure our fax number (281-565-2009) is provided to the labs and request them to put your name and date of birth on each page. We post normal results to your portal and discuss them during follow-up visits. Whether the results are normal or abnormal, we are committed to providing you with an explanation and next steps. It is your responsibility, however, to schedule follow-up visits to facilitate this. For your convenience we offer tele visits in addition to in-person visits.
Refills: 1. We encourage you to Sign up for auto-refills from your pharmacy. Ensure your pharmacy has the correct medication doses and your current medication list. Ask them to remove outdated or incorrect medications. Contact your pharmacy directly for refills which generates an electronic request for your medicine. 2. Medication refills are generally processed during your office or tele visit. Notify us of any pharmacy changes. If you change your pharmacy you can transfer prescriptions directly by contacting the new pharmacy. Monitor your medication supply and allow up to 5 business days for non-urgent refills. We generally do not prescribe additional medications without first evaluating you if your last visit was more than three months ago. 3. If your pharmacist tells you they did not receive a prescription authorization from us repeatedly it is likely due to a technical glitch. If there is a persistent problem or urgent need, we recommend you come into our office in person so we can address it and even give you samples if you have them available.
Prior Authorization (PA): 1. If your insurance denies coverage for certain medications, consider generic alternatives or cash payment options like GoodRX for name-brand drugs. 2. For PAs, an office visit is required for documentation. Allow up to 10 business days for processing by insurance. Check with your insurance or pharmacy for PA status. • We obtain PAs for procedures as a courtesy. It’s your responsibility to schedule the procedure before the PA expires.
Clinical Portal Usage: Questions requiring a physician’s response via the patient portal may incur a telemedicine charge. You’re responsible for any deductibles, copays, or coinsurance. If insurance declines to pay, a $25 fee per message applies. Never use the portal for emergencies.
Procedures Performed by Other Doctors: 1. We respect your choice of freedom to choose providers. 2. If you are coming to us for a second opinion, we will be glad to do so. We require your complete medical history to be effective. Since our providers are not physically present during the procedure we cannot vouch for the quality of the procedure, but, we can certainly interpret the results you provide us. 3. We might not be able to provide all treatments to all patients. In your best interest it might become necessary to refer you to outside providers. When you or we transfer your care to other specialists or super-specialists we might not continue to have you on our patient panel. In any event we will give you time to transition care and provide emergency care for a period of time.
Our Team-Based Care at Colon Liver Gastro Consultants PLLC (CLGC)
At CLGC, we sometimes work with different types of healthcare providers like Nurse Practitioners, Physician Assistants, and other doctors. They might be our employees, contractors, or even call-sharing physicians, and they’re all here to provide you with great medical care. By signing these forms, you give us permission to treat you. You agree that it means you are giving permission to all our qualified providers to take care of you. But we know that sometimes you might prefer to see a specific person or might want to change who’s on your care team. Just let us know in writing, and we’ll do our best to make it happen. This might mean rescheduling your appointments or procedures for when your chosen provider is available.
If we can’t find someone within our team quickly enough, we might suggest another great provider outside CLGC who fits what you’re looking for. We’re all about making sure you get timely and efficient care, while also looking after our other patients.
Remember, this agreement covers all kinds of care situations – whether it’s a hospital visit, an office appointment, procedures, phone calls, or discussing lab results. And no matter who sees you, you always have access to your medical records to see what care you’ve received.
While we make every effort to answer phones and take care of issues in real time, it is not always possible to do so without making you wait for long periods of time until staff become available. We encourage patients to leave voice mail in our system which we will follow up or use the messaging service to leave a message at 832-621-3334. This allows for accountability, documentation, and avoids miscommunication.