Please bring this with you to your next appointment.
Billing and Insurance
Our office contracts with most insurance companies. Your Insurance company provides you with proof of insurance that must be presented prior to all services. We bill all primary insurance plans for our patients. Payment for co-payments, deductibles, and payment for any non-covered service is required at the time of your visit. If you have no insurance, your account will be treated as a cash account and we will collect payment in full at the time of service.
Your individual insurance plan is an agreement between you and your insurance company. It is necessary for you to know the specific details of your plan. If your plan requires a referral for specialty services, it is especially important to notify us if there are restrictions on referrals to outside facilities for services. It is your responsibility to arrange for all appropriate referrals and authorizations required for insurance payment. You will be liable for all charges billed for outside providers if they are not contracted with your plan and you have not received the proper pre-authorization. It is your responsibility to know if you referral has expired and to obtain a new referral if needed.
Off Site Links and Other Resources
You do not have to give personal information in order to visit Mississippi Coast Urology’s web site. However, when viewing this website you may encounter opportunities to provide personal information in order for Mississippi Coast Urology to better meet your needs. The information you provide will not be sold, traded, or leased to outside organizations other than South Mississippi Surgeons, South Mississippi Surgical Weight Loss Center and Mississippi Coast Urology without your prior written consent.
Voluntary information submitted through our website is sent by e-mail directly to professional personnel at Mississippi Coast Urology when you click “Submit” in the information form. The information you provide is not stored on the server hosting this website.
All information contained in this web site is copyright protected, unless otherwise noted. Information may be reprinted and/or downloaded for personal use only. Permission to reprint or electronically reproduce any document or graphic in whole or in part for any non-personal or commercial use is prohibited unless prior written consent is obtained from the respective copyright holder(s).
By using this site, you agree that you understand and accept the terms listed above. If you do not agree to these terms, you may not use this site. Privacy as it applies to the Internet is a rapidly developing area. We reserve the right to change our privacy practices from time to time, and will include any changes on this site.
REGARDING YOUR HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
If you have any questions about this notice, please contact:
SMS MANAGEMENT PRIVACY OFFICER
Attn: DON DAVENPORT
2525 TELEPHONE ROAD
Pascagoula, MS 39567
This notice describes the privacy practices of SMS MANAGEMENT and those of any health care professional authorized to enter information into your clinical chart, all departments and organizations associated with SMS Management, all employees and staff, all these entities, sites and locations follow the terms of this notice. They may share medical information with each other for treatment, payment or clinical operations purposes described in this notice. Any Business Associate of these entities that performs services for or on behalf of these entities is required by us to enter into a contract in which it undertakes to accord the same level of confidentiality to personal information that we afford.
OUR PRIVACY PRACTICES REGARDING MEDICAL INFORMATION
In order to provide you with quality care and to comply with legal requirements, we create a record of the care and services you receive in our clinic and from our health care professionals. We understand that medical information about you and your health is personal. We are committed to maintaining the confidentiality of medical information about you. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. We are required by law to: Make sure that medical information that identifies you is treated confidentially; Give you this notice of our privacy practices with respect to medical information about you; and Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment we may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you both in and outside the clinic.
For Payment we may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about surgery you received so that your health plan will pay us or reimburse you for the surgery. We also may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations we may use and disclose medical information about you for our health care operations. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We also may disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. The medical information we have may be combined with medical information from other sources in order to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
For Appointment Reminders we may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the clinic. For Health-Related Benefits, Products and Services we may use and disclose medical information to tell you about health-related benefits, products or services that may be of interest to you. Unless you request that we not do not, we may release medical information about you to Individuals Involved in Your Care or Payment for Your Care, or to a friend or family member who is involved in your medical care. We also may give information to someone who helps pay for your care.
In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may disclose medical information about you to people preparing to conduct a research project – for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the clinic.
As Required By Law we will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety we may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
We may disclose medical information about you for public health activities. These activities generally include the following: to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. We may disclose medical information in response to a court or administrative order, subpoena, discovery request or other lawful process under certain circumstances. Under limited circumstances such as a court order, warrant or grand jury subpoena, we may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
We may disclose medical information in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information, concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises and crimes in emergencies.
We may release medical information to a coroner or an examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We also may release medical information about patients of the clinic to funeral directors as necessary to carry out their duties. We may release medical information about to authorized federal officials for intelligence , counter intelligence, and other national security activities authorized by law. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we retain about you:
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy your medical information, you must submit your request in writing. We have a special form for that purpose that can be obtained from the SMS Records Custodian at 2525 Telephone Road, Pascagoula, MS 39567, Phone 228-762-4483. If you request a copy of the information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.
Right to Amend. You may request that we change your medical information. You must make your request in writing. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information you want changed.
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made, other than for treatment, payment or healthcare operations, of medical information about you. To request this accounting of disclosures you must submit your request in writing to SMS Records Custodian at 2525 Telephone Road, Pascagoula, MS 39567, Phone 228-762-4483.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Request for restrictions should be addressed to Records Custodian at 2525 Telephone Road, Pascagoula, MS 39567, Phone 228-762-4483.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. Your request must be submitted to the Records Custodian at 2525 Telephone Road, Pascagoula, MS 39567, Phone 228-762-4483 in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each clinic. The notice will contain on the first page, in the top right hand corner, the effective date.
If you have any questions about this notice or believe your privacy rights have been violated, you may file a complaint with the clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with the Clinic contact SMS Privacy Officer, at (228) 809-1238 or you can mail the complaint to: SMS Privacy Officer 2525 Telephone Road Pascagoula, MS 39567.
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.