REPORT DELIVERY METHOD
SPECIMEN PICK UP
*BILLS WILL BE SENT OUT EVERY TWO WEEKS.
ORDERING PHYSICIAN(S) INFORMATION
Please provide full name, credentials (MD,DO,DPM,PA,NP,FNP,RNA), and NPI #
CRITICAL VALUES DELIVERY
A critical laboratory value is a result that is significantly outside the normal range and requires prompt medical attention as it may indicate a life-threatening situation. Communication of critical values must reach a licensed caregiver and results must be read back to laboratory staff. Our policy is as soon as a critical result is available, the value will be verbally reported within 30 minutes. At least three attempts will be made. The final report indicating a critical value will also be faxed as soon as it is available, but is not sufficient notification. Results cannot be communicated via e-mail or text message, and pagers or answering services will only be used to notify the provider of the need to contact the laboratory for a critical value. Attempts will be made during the laboratory business hours, and every attempt will be made to communicate results prior to end of business.
CONFIDENTIALITY AND PORTAL ACCESS ACKNOWLEDGEMENT AND AGREEMENT
Apollo Laboratories, its affiliates and related organizations (collectively, the “Organization”) hereby agree to grant me, the undersigned, access to the Organization’s online portal and access to certain medical information and data (the “Portal”), subject to and contingent upon the terms set forth below. In exchange for the grant of access, and as a continuing obligation to maintain limited access to the Portal, I, the undersigned, by my signature below, hereby acknowledge and agree to abide by the following terms, conditions and rules:
Permitted and Required Access, Use and Disclosure:
I acknowledge that I may obtain confidential patient, clinical, and employee related information, and proprietary information about the business and financial interests of the Organization and its business partners, including access to non-public patient and business information of the Organization (collectively referred to as “Confidential Information”). Confidential Information further includes, but is in no way limited to, information concerning patients, participants of benefit plans and programs, protected health information, customers, contractors of the Organization, credentialing, peer review, quality review, committee records, salary and compensation information, logon and password information, health information and information related to the operations and internal business affairs of the Organization that are not generally available to the public. I understand that I may learn of or have access to some or all of this Confidential Information through the Organization’s Portal or through my interactions with the Organization. I understand that Confidential Information is valuable and sensitive and is protected by law and by the Organization’s Policy. The intent of these laws and policies is to ensure that Confidential Information will remain confidential and will be used only by those with appropriate authority as necessary to accomplish the Organization’s mission. I agree to comply with all existing and future Policies and Procedures concerning the security and confidentiality of Confidential Information.
I will access, use or disclose Confidential Patient Information (PHI) only for legitimate purposes of diagnosis, treatment, obtaining payment for patient care, or performing other healthcare operations functions permitted by HIPAA, including all applicable state and federal laws and regulations governing the same and I will only access, use or disclose the minimum necessary amount of information needed to carry out my job responsibilities.
I will access, use or disclose Confidential Information only for legitimate business purposes of the Organization.
I will protect all Confidential Information to which I have access, or which I otherwise acquire, from loss, misuse, alteration or unauthorized disclosure, modification or access including:
I will disclose Confidential Information only to individuals, who have a need to know to fulfill their job responsibilities and business obligations.
I will comply with the Organization’s access and security procedures, and any other policies and procedures that reasonably apply to my use of the computer systems and/or my access to information on or related to the computer systems including off-site (remote) access using portable electronic devices.
Prohibited Access, Use and Disclosure:
making sure that paper records are not left unattended in areas where unauthorized people may view them;
using password protection, screensavers, automatic time-outs or other appropriate security measures to ensure that no unauthorized person may access Confidential Information from my workstation or other device;
appropriately disposing of Confidential Information in a manner that will prevent a breach of confidentiality and never discarding paper documents or other materials containing Confidential Information in the trash unless they have been shredded; and
safeguarding and protecting portable electronic devices containing Confidential Information including laptops, smartphones, PDAs, CDs, and USB thumb drives.
Accountability and Sanctions:
I will not access, use or disclose Confidential Information in electronic, paper or oral forms for personal reasons, or for any purpose not permitted by the Organization policy, including information about co-workers, family members, friends, neighbors, celebrities, or myself. I will follow the required procedures at Organization to gain access to my own PHI in medical and other records.
I will not use another person’s login ID, password, other security device or other information that enables access to the Organization’s computer systems or applications, nor will I share my own with any other person.
If my association with the Organization ends, I will not subsequently access, use or disclose any Organization Confidential Information and will promptly return any security devices and other Organization property.
I will not engage in any personal use of the Organization’s computer systems that inhibits or interferes with the productivity of employees or others associated with the Organization’s operations or business, or that is intended for personal gain.
I will not engage in the transmission of information which is disparaging to others based on race, national origin, sex, sexual orientation, age, disability or religion, or which is otherwise offensive, inappropriate or in violation of the mission, values, policies or procedures of the Organization.
To the extent applicable, I will not utilize the Organization network to access Internet sites that contain content that is inconsistent with the mission, values and policies of the Organization.
I will immediately notify the Organization’s Security Official or Privacy Official if I believe that there has been improper/unauthorized access to the Organization’s Portal or improper use or disclosure of Confidential Information in electronic, paper or oral forms.
I understand that the Organization will monitor my access to, and my activity within, the Organization’s Portal, and I have no rightful expectation of privacy regarding such access or activity.
I understand that if I violate any of the requirements of this Acknowledgement and Agreement, I may be subject to disciplinary action, my access may be suspended or terminated and/or I may
be liable for breach of contract and subject to substantial civil damages and/or criminal penalties.
In the event my login ID, password or other information that enables access to the Organization’s portal is compromised, I will report such information to the Organiza tion’s Security Official or Privacy Official immediately.
I understand that my use of the software on the Organization’s Portal is governed by the terms of separate license agreements between the Organization and the vendors of that software.
I agree to use such software only to provide services to benefit the Organization.
I will not attempt to download, copy or install the software on any other computer.
I will not make any change to any of the Organization’s systems without the Organization’s prior express written approval.
The following provisions apply to physicians / physician practices; other individual or facility providers; vendors that are not a business associate of the Organization or any other unaffiliated organization:
I understand that access to the Organization’s Portal is “as is”, with no warranties and all warranties are disclaimed by the Organization.
The Organization may suspend or discontinue access to protect the Portal or to accommodate necessary down time. In an emergency or unplanned situation the Organization may suspend or terminate access without advance warning.
The Organization may terminate this agreement, user access and use of Confidential Information at any time for any reason or no reason.
I accept responsibility for all actions and/or omissions by my employees and/or agents.
I agree and will ensure that each employee and/or agent of my organization or practice will be required to obtain a separate login, password and I will not authorize or permit, under any
circumstance, any person to utilize the logon, password or individual information of another person.
I agree to notify the Organization within 5 business days if any of my employees or agents who have access to the Organization’s portal no longer need or are eligible for access due to leaving my practice/company, changing their job duties or for any other reason.
I agree to report any actual or suspected privacy or security violations made by my employees and/or agents to the Organization Privacy Official or Security Official.
I understand that the Organization may terminate my employee and/or agent’s access in their sole and absolute discretion.
I also acknowledge that I may be subject to penalties or liabilities under state or federal laws. I understand that if the Organization prevails in any action to enforce this Agreement, the Organization will be entitled to collect its expenses, including reasonable attorneys’ fees and court costs from me.
EXCERPTS FROM THE GUIDELINES PER THE FEDERAL REGISTER FOR DIAGNOSTIC LABORATORY TEST 42 CFR 410.32 AND 411.15
DOCUMENTATION AND RECORD KEEPING REQUIREMENTS
Ordering the Service
The physician (or qualified provider) who orders the service must maintain documentation of medical necessity in the beneficiary's medical record.
Submitting the Claim
The entity submitting the claim must maintain the following documentation:
- The documentation that it receives from the ordering physician or NPP practitioner.
- The documentation and the information that it submitted with the claim accurately reflects the information it received from the ordering physician or NPP.
Requesting Additional Information
The entity submitting the claim may request additional diagnostic and other medical information to document that the services it bills are reasonable and necessary. IF the entity requests additional documentation, it must request material relevant to the medical necessity of the specific test(s), taking into consideration current rules and regulations on patient confidentiality.
Upon request by CMS, the entity submitting the claim must provide the following information:
contact the ordering physician or NPP).
- Documentation showing accurate processing of the order and submission of the claim.
- Diagnostic or other medical information supplied to the laboratory by the ordering physician or NPP, including any ICD-10-CM code or narrative description supplied.
Services that are NOT Reasonable and Necessary
If the documentation does not demonstrate that the service is reasonable and necessary, CMS takes the following actions:
- Provides the ordering physician or NPP information sufficient to identify the claim being reviewed.
- Requests from the ordering physician or NPP those parts of a beneficiary's medical record that are relevant to the specifuc claim(s) being reviewed.
- If the ordering physician or NPP does not supply the documentation requested, informs the entity submitting the claim(s) that the documentation has not been supplied and denies the claim.
I understand that as a policy, Apollo Laboratories provides convenient options for clients and assists in the best patient care possible. Apollo offers custom panel options to all of their physicians. This panel allows each physician to
any combination of individual tests. I certify that the tests ordered are medically necessary. I agree to contact Apollo
time if needed.
I understand and agree to the statement above. I authorize Apollo Laboratories to perform the custom panel that I have designated on this form, as I authorize it for my patients and their order forms. At any time, I can modify my custom panel by contacting Apollo and may also order individual tests on any specimen.
I understand and agree to the Physician Acknowledgement and Authorization Statement above.