PATIENT CENTER

POLICIES AND FORMS 

New Patients

New patients, please follow the steps below to prepare for your first visit.

  1. Download the Patient forms.

  2. Print the form, fill in your information.

  3. Call us to schedule an appointment at (480) 610-8183.

  4. On the day of your appointment, bring the completed forms and a valid insurance card.

  5. Arrive 20 minutes early.

NOTE: If patient forms are not filled out before arriving for your appointment, please arrive 30 minutes early.

The Owensby team will happily assist you.

Patient Forms

Click on the form to download and print.  Be sure to bring the completed forms 20 minutes before your first appointment.

Patient

Demographics

Medical

History

Privacy Policy

Late Arrivals

The policy below is the same for those who arrive late for appointments, failure to cancel appointments and for those who do not show up at all for their scheduled appointments.

If you arrive more than 10 minutes after your scheduled appointment time, we reserve the right to reschedule your appointment. A notice of at least 24 hours must be given to reschedule or cancel an appointment or a cancellation charge of $25 may be billed to you.

Payment

We accept Cash, Checks, Visa, Mastercard. (we do not accept American Express)Copays are due at time of patient check-in for your appointment. If you decide to pay without the help of any insurance policy, all services must be paid in full at the time of service.

Accepted Insurances

  • AARP Medicare Complete (must have Dr. Jerry Owensby’s name printed on the card)

  • Banner Choice

  • Blue Cross Blue Shield PPO

  • Blue Cross Blue Shield Advantage HMO Banner plan

  • CHAMPVA - Military

  • Cigna PPO, OAP (No HMO)

  • Fortis

  • GEHA

  • Health Net Commercial Plans (No Ruby, Jade or Marketplace)

  • Humana PPO Medicare Replacement (No Humana HMO)

  • Medicare

  • Medicare Replacements: Humana, Aetna, AARP/UHC

  • UHC Medicare Solutions – Plan 1 (No regular PPO)
     

Please note that we are not contracted with any AHCCCS plans.

Returned Checks

For every returned check a $30.00 fee will be charged.  The fee must must be paid in cash or by credit card.

Medical Records Request

A signed medical Records Release form and a $25.00 fee will be required in order to cover the costs of providing copies of medical records and/or completing non-care related information requests. This fee does not apply to medically necessary requests for your ongoing medical care.

Privacy Policy

OUR PLEDGE REGARDING MEDICAL INFORMATION

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

 

Our Legal Duty

Law Requires Us to:

  1. Keep your medical information private.

  2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.

  3. Follow the terms of the current notice.

 

We have the Right to:

  1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.

  2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

 

Notice of Change to Privacy Practices:

  1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

 

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.

 

For Treatment:

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

 

For Payment:

We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

 

For Health Care Operations:

We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employee conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

 

Additional Uses and Disclosures:

In addition to using and disclosing your medical information for treatment, payment and health care operations we may disclose health information when authorized or necessary to comply with laws.

 

YOUR INDIVIDUAL RIGHTS

You have the Right to:

  1. Look at or get copies of certain parts of your medical information. You must make your request in writing. There may be charges for copying and for postage if you want the4 copies mailed to you. Ask the receptionists about our fee structure.

  2. Receive a list of all the times we shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.

  3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).

  4. If you wish to receive a paper copy of this privacy notice, then you Have the right to obtain a paper copy by making a request in writing to our Privacy Officer.

 

If you have any questions about this notice, please ask the receptionist to speak to our Privacy Officer.

Jerry Ellen Owensby, M.D., P.C. Copyright 2020