Sangre de Cristo Internal Medicine

Virtual Primary Healthcare, Medical and Wellness Consultants: Colorado, USA

Terms and conditions of use policy

 

Welcome

Welcome to SDCIM's website and online services (the "Site"), an online information and communications service provided by SDCIM. This policy is intended to cover the uses for all of the Site, although additional conditions, restrictions and privacy policies may apply.

Health care disclaimer

The content, products and services offered herein are here to educate consumers on health care and medical issues that may affect their daily lives. Nothing in the content, products or services should be considered, or used as a substitute for, medical advice, diagnosis or treatment. This site and its services do not constitute the practice of any medical, nursing or other professional health care profession and does not constitute medical advice, diagnosis or treatment. You should always talk to your health care provider for diagnosis and treatment, including your specific medical needs. None of the products or services offered through this website represents or warrants that any particular service or product is safe, appropriate or effective for you. We advise users to always seek the advice of a physician or other qualified health care provider with any questions regarding personal health or medical conditions. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. If you are in the United States and are experiencing a medical emergency, please call 911 or call for emergency medical help on the nearest telephone.

Terms of use

Use of the Site is subject to the following terms of use. SDCIM may modify these terms and conditions at any time, and such modifications shall be effective immediately upon posting the modified terms and conditions on the Site. You agree to review the agreement periodically to be aware of such modifications, and your accessing or using the service constitutes your acceptance of the agreement as it appears at the time of your access or use. 

Intended for users 18 and older

The Site is intended for use by individuals 18 years of age or older. This website is not directed for use by children under the age of 18. Users under the age of 18 should get the assistance of a parent or guardian to use this site.

You agree that you will not:

Upload or transmit any communications or content of any type that may infringe or violate any rights of any party

Use this website for any purpose in violation of local, state, national or international laws

Use this site as a means to distribute advertising or other unsolicited material to any third party

Use this website to post or transmit material that is unlawful, obscene, defamatory, threatening, harassing, abusive, slanderous, hateful or embarrassing to any other person or entity

Attempt to disable, "hack" or otherwise interfere with the proper functioning of this website

If you use any part of the Site requiring secure access, you are responsible for maintaining the confidentiality of your account and password and for restricting access to your computer, and you agree to accept responsibility for all activities that occur under your account or password.

Order limitations

We reserve the right to reject any order you place with us, or to limit quantities on any order, without giving any reason. If we reject your order, we will generally attempt to notify you using the email address you gave us when you placed the order.

Termination of use

SDCIM may, in its sole discretion, terminate your account or your use of the Site at any time. You are personally liable for any orders that you place or charges that you incur prior to termination.

SDCIM reserves the right to change, suspend or discontinue all or any aspects of the Site at any time without prior notice.

Blogs and interactive media

If you or your representatives use blogging features or otherwise post information to the Site or its related social media derivatives, you give SDCIM the irrevocable right to reproduce, distribute, publish, display, edit, modify, create derivative works from and otherwise use your submission for any purpose, in any form, and on any media.

If you use blogging features or otherwise post information to the Site, you agree you will not:

Post material that infringes on the rights of any third party, including intellectual property, privacy or publicity rights

Post material that is unlawful, obscene, defamatory, threatening, harassing, abusive, slanderous, hateful or embarrassing to any other person or entity as determined by SDCIM in its sole discretion

Post advertisements of solicitations for business

Post chain letters or pyramid schemes

Impersonate another person including but not limited to a spouse, child or sibling

Allow another person to use your credentials for posting or viewing comments

Post the same note more than once or "spam"

SDCIM reserves the right (but is not obligated) to do any or all of the following:

Remove communications that fail to conform with these terms of use

Terminate a user's access to the entire Site or specific features such as the blog

Edit or delete any communications posted on the blog features, regardless of whether such communications violate these standards.

eCommerce

One-time charges. A valid credit card number, expiration date and card security code is required for all purchases. If we are unable to charge the full cost of your purchase to the credit card you provide, we may cancel your order or request an alternate form of payment. SDCIM's designated credit card processor will collect your credit card information and related personal information for its use in processing your payment for the products or services ordered by you. Any complaints or grievances regarding the processing of your payment should be addressed to SDCIM at the contact information given below. You understand that the prices for products and services may be changed from time to time, but that the website will reflect current prices.

Responsibility for charges and fees. You are solely responsible for all charges and applicable fees (including delivery charges, taxes and any fees assessed by your bank) associated with your order.

Indemnification

You agree that you will indemnify SDCIM against any damages, losses, liabilities, judgments, costs or expenses (including reasonable attorneys' fees and costs) arising out of a claim by a third party relating to materials you have posted or other actions taken by you on the Site.

 

Disclaimers

YOU UNDERSTAND AND AGREE THAT THE SDCIM SITE AND ANY SERVICES, CONTENT OR INFORMATION CONTAINED ON OR PROVIDED BY SDCIM SITE IS PROVIDED ON AN "AS IS" BASIS. SDCIM DOES NOT MAKE ANY EXPRESS OR IMPLIED WARRANTIES, REPRESENTATIONS OR ENDORSEMENTS WHATSOEVER (INCLUDING WITHOUT LIMITATION WARRANTIES OF TITLE OR NONINFRINGEMENT, OR THE IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE) WITH REGARD TO THE SERVICE OR ANY MERCHANDISE, INFORMATION OR SERVICE PROVIDED THROUGH THE SERVICE. IN ADDITION, SDCIM DOES NOT GUARANTEE THAT USE OF SDCIM SITE WILL BE FREE FROM TECHNOLOGICAL DIFFICULTIES INCLUDING, BUT NOT LIMITED TO, UNAVAILABILITY OF INFORMATION, DOWNTIME, SERVICE DISRUPTIONS, VIRUSES OR WORMS, AND YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR IMPLEMENTING SUFFICIENT PROCEDURES AND CHECKPOINTS TO SATISFY YOUR PARTICULAR REQUIREMENTS FOR ACCURACY OF DATA INPUT AND OUTPUT.

Errors on SDCIM Site

Content, prices, and availability of products and services are subject to change without notice. Errors will be corrected where discovered, and SDCIM reserves the right to revoke any stated offer and to correct any errors, inaccuracies or omissions including after an order has been submitted and whether or not the order has been confirmed and your credit card charged. If your credit card has already been charged for the purchase and your order is canceled, SDCIM will issue a credit to your credit card account in the amount of the charge. Individual bank policies will dictate when this amount is credited to your account. If you are not fully satisfied with your purchase, contact SDCIM to review issues of concern.

Limitations of liability

THE USE OF THE SITE IS ENTIRELY AT YOUR OWN RISK, AND IN NO EVENT SHALL SDCIM BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, EXEMPLARY, PUNITIVE, OR ANY OTHER MONETARY OR OTHER DAMAGES, FEES, FINES, PENALTIES, OR LIABILITIES ARISING OUT OF OR RELATING IN ANY WAY TO THIS SERVICE, OR SITES ACCESSED THROUGH THIS SERVICE, AND/OR CONTENT OR INFORMATION PROVIDED HEREIN. YOUR SOLE AND EXCLUSIVE REMEDY FOR DISSATISFACTION WITH THE SERVICE IS TO STOP USING THE SERVICE. USER HEREBY ACKNOWLEDGES THAT THIS PARAGRAPH SHALL APPLY TO ALL CONTENT, MERCHANDISE AND SERVICES AVAILABLE THROUGH THE SITE. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU.

Links to third party websites

The Site contains links to other sites operated by third parties. These links are available for your convenience and are intended only to enable access to these Third Party Sites and for no other purpose.

SDCIM does not warrant or make any representation about the substance, quality, functionality, accuracy, fitness for a particular purpose, merchantability or any other representation about any Third Party Site or its content. A link to a Third Party Site on the SDCIM Site does not constitute sponsorship, endorsement, approval or responsibility for any Third Party Site. SDCIM makes no representation or warranty as to any products or services offered on any Third Party Site. The conditions of use and privacy policy of any Third Party Site may differ substantially from the conditions of use and legal notices that apply to your use of the Site. Please review the conditions of use for all Third Party Sites for more information about the terms and conditions that apply to your use of Third Party Sites.  You agree that any media is limited in its accuracy by the nature of time dated material and should always be considered in that light.

 

Contact information

If you have any questions about the Service, please contact SDCIM at 719-542-3100

Adapted for use by Sangre de Cristo Internal Medicine (SDCIM) from the Mayo Clinic website published terms and conditions

Updated 9.23.2017

New Patient Registration Forms

Health Maintenance Survey Name: ____________________

Date of Birth: ___/___/_______

Today’s Date: ___/___/_______

 

  1. Immunizations

    1. Last Pneumovax: ________________ (Date, estimates ok)

_____ ( I do not take)

 

b. Last Tdap: ____________________

_____ ( I do not take)

 

c. Ever had a Zostavax Yes _____ (Date) _____ No _____

 

  1. Last Flu Shot __________

_____ (I do not take)

 

  1. Mammogram ( for women)

    1. Last Mammo (recommended yearly):

__________/___________ (Date/ Normal?)

    1. Last Breast Exam: ________________ (Date), Do you want

updated today? ________________ (yes/no)

 

  1. Pelvic/Pap (for women)

    1. Last Pap (recommended every 3 years age 21-65):

______________________ (Date/ Normal?), Do you want

updated today? __________ (yes/no)

    1. Pelvic can also be done for symptoms, Any ongoing pelvic

symptoms? __________(yes/no)

 

  1. Colonoscopy

    1. Last Colonoscopy: _________________ (Date/Normal?)

    2. Follow up recommendations vary based on individual history

 

  1. Prostate ( for men)

    1. Last PSA: ________________________ (date)

    2. Last Prostate Exam: _________________ (date)

 

  1. Dexa ( for women)

    1. Last Dexa: ________________________ (date)

 

  1. Depression Screen:

    1. How is your energy/stress level? ________________________

    2. How are you sleeping? ________________________________

    3. Do you drive a car? __________________________________

    4. Do you have a supportive circle of family and friends? ______

    5. What activities do you enjoy doing? _____________________

 

Please Note

 

If you want information released to a member of your family including lab results, appointments and any other information pertaining to your health, you MUST sign and date below as well as list their information.

 

_______________________________________ /____________________________

Signature/ Date

 

 

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

 

 

 

 

DATE_______________ REFERRING DOCTOR_________________________

NAME Last ____________________ First ____________________ MI __________

ADDRESS ____________________________________________________________

CITY _______________________STATE _____________________ ZIP _________

PHONE __________ PHONE ___________ RACE ________ ETHNICITY _______

SOCIAL SECURITY #___________________ DATE OF BIRTH________________

SEX_____ MARITAL STATUS____________ SPOUSE NAME_________________

EMPLOYER NAME______________________EMPLOYER PHONE____________

EMERGENCY NOTIFICATION_______________________ PHONE____________

RELATIONSHIP TO PATIENT___________________________________________

EMAIL ADDRESS_____________________________________________________

 

Insurance Information

 

PRIMARY INSURANCE ________________________________________________

POLICY HOLDER NAME _______________________________________________

MEMBER ID #__________________________GROUP # ______________________

SECONDARY INSURANCE _____________________________________________

POLICY HOLDER NAME ______________________RELATIONSHIP __________

MEMBER ID# __________________________GROUP # ______________________

 

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Sangre De Cristo Internal Medicine Associates, Douglas Duffee, MD, Mdiv, FACP, to release any information aquired in the course of examination or treatment needed to determine benefits or the benefits payable for related services or for coordination of care.

 

ASSIGNMENT OF BENEFITS: I hereby authorize payment of medical benefits are made directly to above named Doctor for services provided.

 

SIGNATURE ______________________________ DATE _____________________

 

Please Note

 

If you want any information release to your emergency contact person, you MUST sign and date below.

 

SIGNATURE ______________________________ DATE _____________________

 

 

Personal Health Information Policy

 

  1. In our attempt to make information both secure and portable, any patient requested ( or patient representative requested) transfer of medical records can occur by the following methods:

    1. Released directly to you or your representative via your patient portal. Most recent Lab, Mammo, Pap, Colonoscopy, Dexa Scan, EKG and Chest Xray are released for free.

    2. Any custom or larger volume records requests are released to you or your representative at the cost of $25.00 per 3 mb via secure email or password protected thumb drive with payment consenting via the SDCIM store. We DO NOT fax or paper print patient requested records.

 

  1. Please note that SDCIM is participating in CORHIO. This is Colorado’s Health information data base. By Law, Colorado assumes automatic participation.

If you do not want a summary of your health information shared in this system you must “Opt Out”. Your signature below assumes you DO NOT want to “Opt Out”.

 

  1. Please note that SDCIM participates in CPC+. This is Medicare’s program for building strong primary care practices. You must also “Opt Out” if you do not want to have your personal health information shared with Medicare. Your signature below assumes you DO NOT want to “Opt Out”.

 

 

 

____________________________________ ________________________

Signature Date

Dear SDCIM Patient,

 

Medicare now pays SDCIM for the “outside of the office care” we provide you. In order to obtain this reimbursement, we need your consent. By signing this form, you authorize us to perform and bill for complex care coordination when indicated and when appropriate. This may be as often as once a month or as infrequent as never, based on the complexity of your day to day health status. The allowed charge is $40.00 per month and is subject to the same payment and coverage rules as a standard office visit.

 

This care may include but is not limited to Risk Management Calls, Care Coordination Calls, ER/Hospital follow up calls, Electronic access, Administrative Forms, Self Management Support Plans and Communication Calls with other providers.

 

__________________________________ _______________________

Signature Date

 

 

Sangre de Cristo Internal Medicine Associates

 

 

Fees for Services

We would like you to know about your charges in advance. Fees for medical services are based on the cost of medical supplies required, the amount of professional skill involved, and the amount of time spent. The Billing Dept. will be glad to talk to you about your fees. We will be happy to estimate your charges, although due to the nature of diagnosing medical problems, it will be difficult to be precise concerning total charges ahead of time. If you have any questions about your charges, please let us know.

 

Payment at time of Service

Co-Payments are required on the day of your visit. A $10.00 service fee will be assessed if co-pay is not received at time of visit. We can accept cash, check, money order or credit/debit card. (Please note that not all Health Savings Cards are accepted.) We will assess a $25.00 fee on all returned checks. If you have any medical insurance, we will estimate what your personal balance for the service will be after applying your deductable and co-insurance and ask that you pay that amount. (For patients without health insurance, we prefer full payment at the time of service) Credit Cards are accepted.

 

Delinquent Accounts

We want to be understanding and cooperative with everyone in paying their medical bills. The staff will work with you on payment arrangements. For those patients who do not fulfill their obligations after 60 days, it will be considered in everyone’s best interest for those accounts to be referred to our collection agency. Once an unpaid balance is placed with our collection agency, the account must settled through the collection agency office, not with Sangre de Cristo Internal Medicine Associates. Once your account goes into collection status, you will have 30 days to seek a new physician after which we will no longer manage your medical care.

 

Missed Appointments

If you have a total of 3 missed/cancelled appointments, we reserve the right to discontinue medical care. If so, you will have 30 days to transition to a new provider.

 

Physician and Hospital Charges

Charges for medical care provided by Dr. Duffee while you are in the hospital are billed by Sangre de Cristo Internal Medicine Associates. These should not be confused with charges billed by the hospital.

 

A Word about Your Insurance

As a service to you, we will file insurance claims for each of your insurance policies. IT IS YOUR RESPONSIBILTY TO UPDATE THE OFFICE WHEN YOUR INSURANCE INFORMATION CHANGES. It should be understood your insurance policy is an agreement between you and your insurance company to pay certain amounts for medical care. Your physician’s bill is an agreement between you and your physician. You are responsible for full payment of your account, regardless of the status of your insurance claim.

 

Acceptance of Responsibility

I understand that I am financially responsible for all charges whether or not paid by said insurance company. I know that it is my responsibility to notify Sangre de Cristo Internal Medicine Associates of all changes to my account, this includes changes in insurance, address, telephone numbers, emergency contacts, etc.

 

 

Patient’s Signature__________________________________ Date__________________

 

Patient’s Name (Print) _______________________________ Date__________________

 

 

MISSED APPOINTMENTS

 

 

If you have a total of three or more missed or cancelled appointments, we reserve the right to discontinue your medical care. You will then have 30 days to seek a new physician. A missed appointment is also considered if we called and confirmed with you and then you cancelled the day of the appointment.

 

 

 

 

_______________________________________ _______________________

Signature Date

 

6.4.2018