Financial/ Privacy Practice

Financial Policy For

Karen A Watts, N.P., PLC


1. Upon arrival of each visit, you will be asked to verify that the information we have on file for you is correct. By initialing beside each (your address, phone number and current insurance information) you certify that the information is correct. Should it later be deemed that this information (specifically your insurance coverage) is not accurate, you will be liable for all charges for that date of service regardless of who your insurance carrier is. This includes, but is not limited to, all AHCCCS patients who fail to provide Primary Insurance Coverage. New Patients must bring all insurance information. Failure to provide us with a copy of your insurance card will result in a canceled appointment.


2. If you do not have insurance, or if the care you receive is not a covered benefit for your medical plan, you must pay in full at the time of your appointment.


3. Cash patients must pay in full on the time of visit, unless the billing manager has approved payment plan.


4. According to your insurance plan, you are responsible for any and all co-pays, deductibles, and co-insurances.


5. If you have a secondary insurance we will submit the claim to your insurance for reimbursement. Once both insurance plans have paid, YOU ARE RESPONSIBLE FOR ANY BALANCE ON YOUR ACCOUNT.


6. Co-payments are due at the time of service. You will be charged a service fee of $10.00 in addition to your co-payment if the co-payment is not paid at the time of service or by the end of the next business day. Regardless of your insurance carrier.


7. There will be a $25.00 charge on returned checks that needs to be paid in full. After that we can no longer accept personal checks from you. You will be required to pay in CASH.


8. Please allow us to make a photocopy of the front and back of each medical plan ID card and your driver's license or state ID.  Also provide us your date of birth and date of birth of the policyholder for each plan.  We are required to have the Social Security number of the policyholder for each plan.  We only use social security numbers for filing your medical claims and collecting payment due and for hospital records if necessary only.  We do not use social security numbers for any other purpose.


9. We need signed statement from you allowing us to release your medical records to your medical plan(s), and for every medical plan allowing the plan to send payment directly to Karen A. Watts, N.P., PLC.  If any of the information you supply is incomplete or incorrect or if your medical plan has expired, you will be responsible for payment in full.


10. In fairness to the Medical Provider and other patients that are waiting for appointments, we require at least a 24 hour notice when canceling an appointment. You will be charged $25.00 for missed appointment. AHCCCS patients will be reported directly to AHCCCS for each missed appointment.


11. Any account 90 days past due will be turned to collections. A service charge equal to 50% of the account balance will be added to the total amount due.




                    OFFICE POLICIES



OFFICE HOURS:  Monday – Thursday, 8:30am to 5:30pm, Fridays 8:30am to 3pm.

                                  Closed for lunch from 12:30pm to 1:30pm.


TREATMENT OF MINORS:  Patients under the age of 18 years must be accompanied by a

                                                     responsible adult or have written permission for treatment                                          

                                                     from a parent or guardian.




  • The best time to get a prescription refill is at your appointment.
  • If you need to call for refills, do not wait until you have run out.  Most refills require the

Medical Provider's approval.  If the Medical Provider is out for the afternoon, it may be until the next day.

  • Do not call after hours for prescription refills, there is no access to your chart and we may not be able to help you.


NARCOTICS:  If you require use of narcotics, our Medical Provider will refer you to a pain

                           management specialist.


REFERRALS:  Referrals are handled by our Referral Department.  Sometimes this can be

                           done on the same day as your appointment and sometimes it can take a week,

                           depending on your insurance and/or the urgency of your situation.  Someone

                           will contact you as soon as the referral authorization is obtained.  Please

                           understand that it can sometimes take a few weeks to get an appointment

                           with a specialist.  This is not something we have control over.


DISMISSAL:  If you are “dismissed” from the practice it means you can no longer schedule

                         appointments, get medication refills or consider us to be your medical provider.

                          You have to find a doctor in another practice.


                         COMMON REASONS FOR DISMISSAL


  • Failure to keep appointments, frequent no-shows
  • Abusive to staff
  • Failure to pay your bill


Dismissal Process:

We will send you a letter to your last known address, notifying you that you are being dismissed.   You must find another doctor.  We will forward a copy of your medical record to your new doctor after you let us know who your new doctor is and sign a release form.




                         $5 - $25 for the completion of medical forms.  Please allow 7 – 10 days for the

                         completion of these forms.


MEDICAL RECORDS:  We will provide you a copy of your medical records upon

                                            request and for a fee.  You will need to sign a letter of release

                                            prior to having them copied.  Please allow up to 30 days for this

                                            request to be processed.


BILLING:  If you receive a bill from us, it is because we believe it is your responsibility.

                    Please contact your insurance company first if you think there is a problem.

                    If you have any questions about your bill, please call our billing department

                    immediately.  If you cannot pay your entire balance, please call to make

                    payment arrangements.


ACKNOWLEGEMENT:  I acknowledgment that I have received and read a copy of the

                                             Karen A. Watts, N.P., PLC and Financial Policies.





_____________________________________                                    _______________

Signature of Patient or Guardian                                                    Date



  HIPAA Patient Privacy Notice                         








Each time you visit Karen A. Watts, N.P., a record of your visit is made.  This record includes information about your symptoms, examinations, test results, medications you take, your allergies, your medical histories and the plan for your care.  This information we refer to as your health record and it is an essential part of the health care we provide for you.  Your medical record contains personal health information and there are state and federal laws to protect the privacy of your health information.




We will use your information for treatment


Karen A. Watts and clinical staff involved in your care will read and document in your medical record about your examinations, the care planned for you, the care that you receive and the results of that care.  If we need to refer you out to another provider, Karen A. Watts may send copies of your medical record to the provider that you have been referred to.


If necessary we will provide another health care provider or specialist, who will be treating you, we will send copies of information from your medical record, or possibly a copy of the entire record, that could assist him or her in treating you.


We may also use information from your medical record to call you or send a letter to remind you about an appointment, to follow-up with diagnostic test results, to advise you of your treatment status, or to provide you with information about other treatment and care that could benefit your health.


We will use your health information for payment


A bill may be sent to you or your third party payer (insurance).  The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures performed, and supplies used.  We also may contact your insurance company to determine if they will pay for your care as part of their certification process.