Performance Injury Care & Sports Medicine has adopted this Notice of Privacy Practices and Acknowledgement Policy to be in compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) to protect the confidentiality of protected health information. Patients and/or their guardian/representative will be given the Notice of Privacy Practices upon check-in. All patients must sign an acknowledgement statement showing they have received the notice.
As a courtesy to you, we will bill your insurance company. If your policy has a co-pay. this will be required at the time of service. If your insurance company does not pay us in a timely manner, the bill will become the responsibility of the patient.
If you do not have insurance, it is our policy to collect payment in full at the time of service. A 10% discount will be given for payment in full at the time of service. We accept cash, check and most major credit cards as forms of payment. Payment arrangements may be made by contacting our billing department at (406) 422-5817.
We assign all financial responsibility to the parent/guardian that completes and signs the patient registration forms. Any amount due at the time of service is expected from the parent/guardian accompanying the minor to the visit. Minors without a guardian/parent will be rescheduled.
Statements are sent out every 3-4 weeks.
As a patient, you will be require to sign a form acknowledging the following:
- I consent to examination, treatment and procedures which may be performed during office visits including emergency treatment considered necessary by the physician and/or his designated providers.
- I authorize the release of any medical information necessary to determine benefits payable for insurance claims for services rendered and agree that all proceeds of insurance are assigned to this office where applicable.
- I understand that I am financially responsible for all charges whether or not paid by my insurance. If no insurance payment after 90 days the balance becomes my responsibility.
- I understand that should I default on payment of my account and collection agency services are required, all costs of collections up to 50% of the balance, including attorney/court costs will be added to the balance of my account.
Individuals who have been a patient of Performance Injury Care & Sports Medicine have the right to access or receive copies of their medical records. An Authorization for Disclosure of Medical Information must be on file to release this information.
There is a fee for copies of medical records based upon the request and the number of pages requested. Copies of x-rays are also available on CD for $5.00.
We will have records available within ten (10) days unless they cannot be found or unusual circumstances have delayed handling the request.
Performance Injury Care & Sports Medicine, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
At Performance Injury Care & Sports Medicine, we recognize that privacy is important. This statement outlines the types of personal information we receive and collect as well as some of the steps we take to safeguard information. We hope this will help you make an informed decision about sharing personal information with us.
Personal information and other data we collect:
Performance Injury Care & Sports Medicine records information when you visit our website, including the URL, IP address, browser type and language, and the date and time of your visit. We remain in compliance with regulations concerning personally indentifiable information. This information is never stored by us. At some point in the future, PICSM will begin offering pre-registration forms online to expedite your visit to our clinic. PICSM will utilize a Secure-Socket Layer (SSL) certificate for the collection of any personally identifiable information to encrypt this data prior to transmission over the Internet. Once this service is available, we will provide a more detailed explaination of this process and our committment to keeping this data safe.
For more information about our privacy practices, please feel free to contact us. For information concerning the technical aspects of protecting your information, you may contact our web developer: