General Consent to Treat
You consent to reasonable and necessary medical examinations, testing, and treatment by OV and its physicians and other providers. You understand that providers involved in or observing your care or treatment may include resident physicians and students or other trainees. You are aware that the practice of medicine (including surgery) is not an exact science, and no one has made any guarantees about the results of your treatments, examinations, or procedures. You may be asked to sign other informed consent forms for specific surgeries or procedures.
Patient Rights and Responsibilities
At OV, we are committed to optimizing your experience as our patient. We have established the following rights and responsibilities to outline the collaborative effort between patient and physician in a mutually respective relationship.
Patient Rights. As an OV patient, you have the right to:
- To courtesy, respect, dignity, and timely, responsive attention to your needs.
- To receive information from your providers necessary for informed consent, including the specific procedure/treatment, significant medical risks, and probable duration of incapacitation.
- To have the opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing or not complying with treatment or therapy.
- To be provided, to the degree known, with complete information concerning diagnosis, treatment and prognosis and to have the appropriate assessment and management of pain.
- To ask questions about your health status or recommended treatment when you do not fully understand what has been described and to have your questions answered.
- To make decisions about the care the physician recommends and to have those decisions respected, except when medically contraindicated. A patient who has decision-making capacity may accept or refuse any recommended medical intervention.
- To continuity of care, including that your physician will cooperate in coordinating medically indicated care with other health care professionals, and that the physician will not discontinue treating you when further treatment is medically indicated except as permitted under Virginia law.
- To know the names and professional status of individuals providing service to you and to know the physician primarily responsible for your care.
- To have the physician and other staff respect your privacy and confidentiality and to expect that all disclosures, communications, and records are treated confidentially in accordance with applicable law.
- To obtain copies or summaries of your medical records and to have the information explained or interpreted as necessary, except when restricted by law.
- To obtain a second opinion and to be informed of your right to change providers, either primary care or specialty, if other physicians are available to meet your needs.
- To be advised of any conflicts of interest your physician may have in respect to your care.
- To be provided with methods of effective communication.
- To receive services without regard to race, color, age, gender, sexual orientation, religion, marital status, handicap, national origin or sponsor.
- To be provided reasonable physical access to our facilities and to be provided with a safe environment.
- To receive services in a language you understand and in a culturally-sensitive way.
- To be informed as to key information and policies, including those addressing treatment for unaccompanied minors, expected conduct and responsibilities of patients, services offered, information on after hours and emergency care, fees for services, payment responsibilities, right to refuse participation in research studies or clinical trials, how to file a complaint or express a grievance without retaliation, and ownership disclosure.
Patient Responsibilities. As an OV patient, you have the following responsibilities:
- To demonstrate behavior that shows respect and consideration for other patients, family, visitors, all health care personnel and property of OrthoVirginia facilities.
- To provide accurate and complete information about your medical conditions, health history, demographics and insurance information and to provide updates when this information changes.
- To ask questions and seek clarification until you fully understand.
- To accept the consequences of your actions if you should refuse a treatment or procedure, or if you do not follow the plan of care given to you by the physician or other health care providers.
- To keep appointments, cancel appointments, and notify OrthoVirginia of these changes.
- To assure that the financial obligations for health care rendered are paid.
- To be responsible for your valuables that you bring to OrthoVirginia facilities.
- To provide positive and negative feedback in a constructive and appropriate manner about the care you have received at OrthoVirginia.
- To follow the policies, rules, regulations and procedures of OV.
If you fail to follow medical instructions, display disruptive behavior or have others accompanying you who display disruptive behavior, cancel or do not show for 3 or more appointments, or fail to remain current on your payments, we may terminate the patient/provider relationship.
Your Insurance and Co-Payment
A copayment, or copay, is a fixed amount established by an insurance plan for sharing the cost of certain health services. Copayments are predetermined and should be outlined in your health insurance plan. It is your responsibility to understand your coverage guidelines including corresponding copayments.
Some things you should know:
- If your insurance requires a co-pay, it is the policy at OV to collect it at the time of service;
- If you do not pay your co-pay, you are violating your insurance contract;
- OV reserves the right to reschedule your appointment if your co-pay is not paid at the time you check-in; and
- If OV does not participate with your insurance company, you are likely out-of-network and your financial obligation will be more.
If you have sustained an injury or have been involved in an accident, OV will file claims with your personal health insurance company. If claims are denied by your personal health insurance, OV will provide an itemized statement to you so that you may file directly to the third-party liability insurance carrier that may be covering the accident (automobile insurance, homeowners, accident insurance, etc.) (“Liability Carrier”).
You understand that OV will not hold your account open during any period of litigation or negotiation you may have with a Liability Carrier. Likewise, you understand OV has the right to pursue collection action against you during that period for outstanding financial balances.
You agree to assign the proceeds of your personal injury claim to OV in an amount equal to the total of all sums due and you acknowledge the balance due may include additional fees relative to interest accrued, collection agency costs, and/or attorney fees (equal to 1/3 of the principal balance) if applicable.
Patient Financial Agreement
You consent to OV billing your insurance company, Medicare, Medicaid, Tricare, or any other third-party payer (each a “Payer” and together, “Payers”), as applicable, directly for services rendered by OV and its providers, and you further consent to the payment of medical benefits by your Payer to OV and associated medical providers. You understand that it is your responsibility to secure all necessary prior approvals, authorizations and referrals as required by your Payer(s).
You agree it is your responsibility to provide OrthoVirginia with the correct billing information. You hereby authorize OV to release any health information to any and all applicable Payers and appropriate third parties as determined by OV for eligibility and payment purposes. This release will be considered valid until revoked by you in writing. You authorize any holder of medical or other information about you to release to Medicare and its agents any information needed to determine available insurance benefits.
If you have any financial responsibility, OV may require a deposit prior to service. Otherwise, OV expects payment within thirty (30) days of your receipt of OV’s billing statement.
You agree you are financially responsible for all charges made to your account whether or not a Payer or attorney is involved with payment. You are responsible for all co-payment and co-insurance amounts, non-covered supplies and services, and annual deductibles. OV will file claims with your insurance company as a courtesy.
If you have an outstanding balance due, you agree to a prompt payment in full. If you are unable to make payment in full, you can contact OV’s billing call center at 866-706-7846 for possible payment arrangements. In the event your account is turned over to a third-party collection vendor, you grant authorization for information to be released regarding your employment status to OV or to the collection agency and/or collection attorney. OV’s collection process can start 30-days after the first billing cycle.
If your account, or that of the individual you are guaranteeing, should be placed with a collection agency and/or collection attorney for collection, you agree to pay, in addition to all other amounts you owe, any and all costs of collection including, without limitation, an attorney fee equal to one-third (1/3) of your outstanding balance and other costs associated with collection. If any indebtedness is not paid in full within 60 days from the date of service, you agree to pay interest at a rate of 1.5% per month [18% per annum]. All returned checks will incur a returned check fee of $50.00.
If you are without health insurance at the time of service OV may offer a discount to your charge(s). Payment of the reduced amount must be received?within?30 days from the date of service.? If payment is not received by OV within that time the discount will be revoked, and you will be responsible for the full amount of any outstanding charges.
We reserve the right to charge a fee for a cancellation of less than 24-hour notice or failure to keep an appointment.
Notice of Financial Interest
OrthoVirginia, Inc. offers services and products to patients which provide an appropriate continuum of care for treating musculoskeletal issues. OrthoVirginia and its individual providers have a financial interest in these services and provide them for your convenience and under OrthoVirginia ownership and supervision. These services include the following:
- The Boulders Ambulatory Surgery Center, the Bremo Road, Shrader Road and Herndon Operatories, and the Surgery Center of Lynchburg. Several Northern Virginia surgeons have an ownership interest in centers in suburban Maryland.
- Physical and occupational therapy services in multiple locations.
- MRI imaging centers at the Johnston Willis, Henrico Parham, Lynchburg and Tysons Corner locations.
- Ideal Protein weight loss services in Lynchburg and Northern Virginia.
- Bracing services within OrthoVirginia offices.
OrthoVirginia feels these services offer quality and value, but all patients have the right to choose where they will receive these services. If you prefer to choose another option, let our staff know and OrthoVirginia will work with you in providing alternate and appropriate solutions.
Medication Prescription Policy
- Each prescription will be for a fixed amount of medication (a limited supply will be issued for a short duration). You should take the medication exactly as prescribed. Medication will not be increased or renewed early unless the provider feels it is appropriate to do so.
- Telephone calls for prescription refills will only be renewed by the treating provider during business hours. The on-call physician after hours will only entertain telephone calls regarding adverse reactions to your medications. Please note medication refill requests may take 48 business hours to complete.
- We participate with, and may review, the Commonwealth of Virginia Department of Health Professions (DHP) Prescription Monitoring Program (PMP). If there is evidence of prescription pain medicines being obtained or requested from another provider, you will not be able to request or obtain those prescriptions from our providers.
- In following with the Board of Medicine’s new requirements (18 VAC 85-21-10 et seq.) for treating chronic pain (pain lasting longer than 3 months) all physicians will be required by state law to obtain urine drug screens or serum medication levels at the initiation of chronic pain management and randomly thereafter at the discretion of the practitioner but at least once a year.
- Appointments must be kept or cancelled 24-hours prior to the scheduled time, for medications to be extended. Medications may be discontinued due to repeated cancellations or failing to show for appointments.
- It is your responsibility to prevent loss of prescriptions or medications. Do not expect lost or stolen prescriptions or medications to be replaced, regardless of the situation. A police report is required for all claims of theft.
- In the interest of your physical well-being, it is strongly recommended that you be under the care of a primary care physician. OrthoVirginia providers may prescribe medications while you are actively undergoing treatment. Our providers do not provide long-term medication management. Your primary care physician will be responsible for the medical management of your pain on a long-term basis, provided he or she is in agreement with the long-term usage of pain medications.
- You will be asked to actively participate in other recommended treatments such as physical therapy, home exercise program, procedures, testing, and/or other medications. If you are unable to participate you will need to make your provider aware of any reasons that prohibit participation. You must keep us informed of any changes in your condition such as pregnancy, change in provider, change of pharmacy, and Emergency Room visits.
There are limitations and side effects of pain medications including but not limited to sedation, dizziness, drowsiness, nausea, vomiting, constipation, physical dependence, tolerance, respiratory depression, overdose, and even death.
Any deviation from this policy is at the sole discretion of the prescriber and does not guarantee future deviations. Violation of any of the above can result in discontinuation of medication prescriptions and possible discharge from OrthoVirginia.
Deemed Consent for Blood Sample Withdrawal and Testing
Under Code of Virginia § 32.1-45.1, you consent to the withdrawal of a blood sample from yourself, your child, or an individual over whom you have guardianships’ body, in the event that an OV employee or physician sustains an exposure to the aforementioned’ s blood or body fluid. In OrthoVirginia’s Richmond, Northern Virginia, and Virginia Beach regions, you agree to go immediately to the nearest Patient First for the collection of a blood sample. In Lynchburg, you agree to go immediately to the OrthoVirginia in-house lab to have a blood sample collected. If the exposure occurs in an OrthoVirginia Operatory or Pain Management, you agree to the immediate collection of a blood sample by the Operatory staff. You agree to the testing of the blood sample for human immunodeficiency virus (HIV), hepatitis B, and hepatitis C, at no cost to you, and to the release of the test results to the exposed employee and provider(s) treating them.
Electronic Health Record and Patient Portal Acknowledgement
Epic is OV’s electronic health record. We use Epic to create an electronic chart with your health information, including but not limited to your office notes, x-ray images, and a record of your encounters. You authorize OrthoVirginia to use the Epic electronic health record to electronically send and receive PHI pertinent to your care. This includes texts, images and x-ray files.
OV offers a patient portal to its patients, where they can access certain health information about themselves, request appointments, and send communications to OV staff and providers. If you choose to enroll in the patient portal (MyChart), you give OV permission to send your health information through MyChart for your personal access and use, including messaging, images, and x-ray files. Please review the MyChart Terms and Conditions at the bottom of the MyChart website. Uses and disclosures of information in MyChart by OV are governed by this Notice and federal and state privacy laws. If you wish to terminate access to MyChart, you can contact OV by sending a message via MyChart, or you can call our MyChart Patient Support Line at 1-877-701-6088.
OV collects e-mail addresses from our patients if they choose to provide them to us. We use e-mail to send appointment reminders, surveys, and notifications to you about our practice. If you subscribe to MyChart, MyChart will send you notification emails for activation, appointment reminders, and payment purposes. We consider your e-mail address to be a part of your protected health information. You are not required to provide us with your e-mail address; however, it will limit our ability to communicate with you. If you provide us with your email and later decide you would like to unsubscribe, you may let us know by sending a message via MyChart or calling our MyChart Patient Support Line at 1-877-701-6088, and we will remove your email address from our electronic health record.
Our policies require us to email health information to you encrypted or via MyChart. If you tell us you want to receive unencrypted email, that email will not be secure. Unsecure emails may be viewable by others. You must provide us with a statement in writing (e.g., letter, email, MyChart message) that you do not want email with your health information to be encrypted. You understand that if you ask us to send an unsecured email, you are assuming this risk.
Telephone Calls and Text Messages
OV collects residential and cellular telephone numbers provided to us and may use these numbers to communicate with you about your treatment, your appointments or procedures, to service your account or to collect any amounts you may owe. If we contact you by cell phone number, this could result in charges to you. We may also leave a message on voice mail in reference to any items that assist the practice in carrying out treatment, payment or our internal operations, such as appointment reminders, insurance items, and any call pertaining to your clinical care, including laboratory results.
We do not generally text patients their personal health information for security reasons. Certain text messages contain minimal information and may be sent using pre-recorded/artificial text messages and/or use of any automatic dialing device. For example, we may text you automated appointment reminders, prompts to sign up for MyChart, the availability of test results or a billing statement in MyChart, or requests to provide feedback about our services. You agree that OV or its vendors may contact you as described above. If you decide you would like to unsubscribe from any automated phone/text messaging, you may let us know by sending a message via MyChart or calling our MyChart Patient Support Line at 1-877-701-6088, and we will remove you from those features.
Patient Satisfaction and Outcome Surveys
You agree to receive a patient satisfaction survey after a visit to our office. We encourage you to complete it as we use this feedback to educate our team on how we are doing. You are important to our practice and your feedback will help ensure we continue recognizing areas of opportunity that will improve your overall patient experience with us! You also agree to receive a series of outcomes surveys just before and after common orthopedic surgical procedures. You may receive the survey by mail, email or by text message, as described above. Outcomes data is the cornerstone of assuring that our patients receive quality care, so please complete these surveys. OrthoVirginia compares your responses anonymously to national databases to benchmark the quality of care we provide. Thank you in advance for taking time to complete the surveys.
Acknowledgement and Acceptance of Policies and Procedures
I acknowledge that I will be asked to agree to the above stated policies and practices of OrthoVirginia, Inc. during registration.
If you have any questions about the Statement of Practice Policies, you may contact the Office Manager at your local OV office.
Changes to this Statement
OV reserves the right to update the practice policies contained in this Statement of Practice Policies at any time. OV will make any revised Statement available on its website and in each office location on or after the effective date of the changes. The updated date below may not be earlier than the date the revised Statement is printed or published.
Updated July 24, 2020