PRACTICE POLICIES & CONSENT TO TREAT

Santa Fe Mobile MD | (505)386-1380 | santafemobilemd.com

We appreciate you for choosing Santa Fe Mobile MD for your care. The doctor-patient relationship is unique in that it is highly personal, and at the same time, contractual. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This document will provide a clear framework for our relationship. Feel free to discuss any of this with us.

Please read carefully, Your signature on this document is an acknowledgement that you have reviewed, understand, and have agreed to the Santa Fe Mobile MD practice policies and are consenting to treatment as set forth herein.

CONSENT FOR CARE

With your signature, you authorize Santa Fe Mobile MD physicians and providers or any employee working under the direction of the physician or provider (either Dr. Stewart Anderson, MD, Dr. Y. Joel Rosen, MD, or Patricia Rosen CNM, CFNP) to provide medical care for you, or a patient for whom you are a legal guardian. The medical care may include provision of services or supplies related to your health (or your dependent’s health) and may include, but is not limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care; counseling, assessment or review of physical or mental status; and the sale, dispensing or administration of medication, equipment or other items as deemed necessary by your care team. You further consent that certain services may be provided under the New Mexico Telehealth Act, as more specifically described below. This consent to treat includes contact and discussion with other health care professionals for care and treatment as deemed necessary by your care team, in accordance with state and federal law.

MOBILE HEALTH SERVICES

Santa Fe Mobile MD is a unique healthcare service provider by providing primarily mobile health services. What this means is that Santa Fe Mobile MD comes to you! By signing this document, you agree to the provision of healthcare services by a Santa Fe Mobile MD practitioner at your location of choice, whether your home, place of business, or a hotel. Santa Fe Mobile MD will maintain respect and privacy in your designated place of services and retains the right to refuse or reschedule your appointment if your home, office, or hotel room are not adequate for the provision of its services.

TELEHEALTH SERVICES

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail are considered telemedicine or telehealth by the State of New Mexico. Under the New Mexico Telehealth Act, codified at NMSA § 24-25-1, et. seq., telehealth is broadly defined as the use of information technology to provide and support health care delivery, diagnosis, consultation, treatment, and transfer of medical data and education. By signing this document, you consent to the provision of telehealth or telemedicine if warranted.

SANTA FE MOBILE MD PAYMENT POLICY

  • We believe in simple, transparent pricing.
  • We have a direct pay model, which means that we do not bill insurance companies.
  • We will adhere to the following financial policies in order to consistently deliver high quality and personalized care.
  • Pricing for services is delineated on our website www.santafemobilemd.com pricing page and may change from time to time without prior notice.
  • By signing below, you acknowledge that you will be responsible for all payments for services within 7 days of services rendered.

APPOINTMENTS AND CANCELLATIONS

  • Please remember to cancel or reschedule 24 hours in advance.
  • Appointments cancelled on the same day as the appointment will be billed the full fee. We make every attempt to accommodate our patients and need to rely on the schedule once it is set. Thank you for understanding.
  • A $35.00 service fee will be charged for any checks returned.

TELEPHONE ACCESSIBILITY

If you need to contact us prior to an appointment, please leave a voice message. We are often not immediately available. However, we will attempt to return your call within 24 hours. If a true emergency situation arises, please call 911 or go to a local emergency room.

COMPLIANCE WITH HIPAA

Santa Fe Mobile MD adheres to strict compliance with the Health Insurance Portability and Accountability Act (known as HIPAA) and all state laws regarding patient privacy and transmission of information.

By signing this document, you acknowledge that Santa Fe Mobile MD may provide your otherwise protected healthcare information to a third-party in the case of any dispute regarding billing or the nature and extent of services provided as related to billing and payment and that Santa Fe Mobile MD is not required to obtain a separate release in order to release such information. By signing this document, you are hereby releasing your healthcare information for purposes of billing disputes, if any should arise.

ELECTRONIC COMMUNICATION

If you prefer to communicate via email or text messaging, we will do so. However, we cannot ensure the confidentiality of any form of communication through electronic media, including text messages. While we will try to return electronic messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Please note that under HIPAA, it is permissible for healthcare providers to send Protected Health Information by SMS text if a patient has initiated a communication by SMS text or exercised their right to request confidential communications by SMS text. By signing this document, you are agreeing and acknowledging that if you (the patient) initiate any communication by text or email containing any Protected Health Information, this shall be construed as your agreement for Santa Fe Mobile MD to provide and transmit Protected Health Information by SMS text. Protected Health Information under HIPAA includes all “individually identifiable health information,” including demographic data, that relates to:

  • the individual’s past, present or future physical or mental health or condition,
  • the provision of health care to the individual, or
  • the past, present, or future payment for the provision of health care to the individual,

and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.

MINORS

If you are a minor, your parents or guardians may be legally entitled to some information about your evaluation and treatment. We will discuss with you what information your parents or guardians are legally entitled to and which matters are kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. We may terminate our doctor-patient relationship after discussion with you if we determine that our recommended treatment is not proving beneficial and if you may be better served by an alternative therapeutic approach or provider.

Expert Medical Care that comes to you!

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