Welcome to our practice!

After Office Hours
For urgent medical issues after regular office hours, please call Dr. Talley's personal mobile number. For all other issues, please call us during regular office hours.

Same Day/Urgent Appointments
We understand that sometimes medical problems come up and you would like to be evaluated sooner than the next available appointment. Please let us know and we will try to accommodate you on the same or following day.

Emergencies
Call 911 for medical emergencies.

Medication Refills
We do not want you to run out of your medications. We recommend that you notify the pharmacist to send us an electronic refill request when you are picking up your last refill.

Forms
Please make an appointment if you have any forms that will require our doctors to fill out. Most forms require an evaluation and possible laboratory testing to complete.

Medical Care
We are concerned about your health. In order for us to provide the best possible quality of care for you, we will need your cooperation in keeping your scheduled appointments, making follow up appointments, scheduling annual physical exams, and completing tests ordered for you.

Cancelling Appointments
If for any reason you will not be able to keep your appointment, we ask that you notify us to reschedule at least 24 hours prior to your appointment.

Other Physicians or Health Care Specialists
If you are seeking health care from other physicians in the community, we would like you to ask their office to send us a copy of their notes and studies.

Communication
We believe in having good communication between our office and our patients. We encourage you to express any questions or concerns to us so that we may better serve you.

Notice of Privacy Practices
A copy of our Notice of Privacy Practices is available upon request.

Personal Medical History

Please list the last date you had any of the following:

Family Medical History

Example: cancer (type), diabetes, heart disease, mental illness, stroke, seizure, etc.

Vaccine History

(most recent)

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

GUARANTOR/POLICY HOLDER INFORMATION

All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. Once the insurance company is billed we allow 60 days for the balance to be paid by your insurance carrier. If the insurance carrier does not remit payment in 60 days, the balance will be due in full from you. If any payment is subsequently made by your insurance carrier in excess of the balance, we will gladly refund the overpayment to you within 30 days, providing that you do not have any outstanding accounts with our office. It is also customary to pay for professional services when rendered unless prior arrangements are made. I request that payment of authorized Medicare/other insurance company benefits be made on my behalf to JATEKO FMG / TCM . Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the social security administration and healthcare financing administration or its intermediaries or carriers, any information needed for this or a related Medicare claim or other insurance claim. I permit a copy of this authorization to be used in place of the original and request that payment of medical insurance benefits be made payable to JATEKO FMG / TCM. I understand that it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment (section 1128b of the social security act and 31 u.s.c 3801-3812 provides penalties for withholding this information). There is a $20.00 charge for all returned checks. All unpaid balances are subject to 1.5% interest or minimum $6.00 service charge after 90 days. If your account must be forwarded to a collection service and/or an attorney because of nonpayment, you will be responsible for all collection fees and/or attorney fees charged by these services.

PATIENT RESPONSIBILITIES

As a partner in your healthcare, you have the following responsibilities:

1. I will provide accurate health information to my doctor and update the practice with any health changes.
2. I will keep my appointments and reschedule any missed appointments. I understand that my doctor schedules these appointments to follow up on my response to treatment and to monitor my medical conditions. During these appointments my physician may order tests, refer me to a specialist, change my medications, and diagnose a medical problem.
3. I understand that the goal of the office is to provide me with test results in a timely fashion. If I do not hear from the office, I will call the office for test results. I understand that not hearing from the office about a particular test does not necessarily mean that the test result is normal.
4. I will inform my doctor if my medical condition changes, does not improve, or worsens. This will allow my doctor to re-evaluate my condition and make changes in treatment.
5. I will fulfill my financial obligations for care provided to me in a timely manner.
6. I will keep my scheduled appointments and give adequate notice of rescheduling or cancellation.
7. I will take responsibility to understand my health plan and be aware of my benefits, deductibles, and health plan limitations. I will ask my health plan if I have any questions regarding my health coverage.
8. If you need information or need to inquire about Advance Directives (Durable Power of Attorney for Health Care, Natural Death Act Declaration or Living Will) please call the Member Services Department of your health plan.

INSURANCE – BILLING – FINANCIAL ISSUES AND MEDICAL RECORDS

JATEKO Family Medical Group (JATEKO FMG) / Talley Concierge Medicine (TCM) makes every effort to process your insurance claims. We bill most insurance companies as a courtesy to you. Your insurance policy is a contract between you, your employer, and the insurance company. If you are questioning your insurance company, our bill must be paid during your appeal. If your insurance company requests you complete an inquiry and you do not respond, we will send you the bill directly. Your non-cooperation with the insurance company makes you financially responsible to JATEKO FMG / TCM and or any other agency we have perform our collections whether in whole or in part. All payments are due at time of service, copayments, coinsurances, deductibles and balance due bills. We do not send statements for balances under $5.00, but will collect the amount at the next office visit.

DEDUCTIBLES, CO-PAYMENTS, CO-INSURANCE AND ALL CASH VISITS ARE DUE AT THE TIME OF SERVICE - If you cannot pay, you must speak with our billing representative before your office visit to set up payment arrangements. If you leave without paying your portion of responsibility, we will bill you an additional $3.00 for processing that bill for this service and payment is expected at the time of service.
All forms requiring the provider's time to complete may require a fee that must be paid at the time of completion. Insurance companies will not pay for this service. Medical records requests over ten pages may require a $0.60 per page fee. We are authorized by the Federal Government to charge for these requests. If you are moving and wait until you select your new provider, we will honor the request from another provider's office and fax at no charge. Should you want a copy of all your records, we may require a $0.60 per page, plus postage if applicable. You must allow JATEKO FMG / TCM one week to process your request. Any archived charts take 30 days to process.

FORMS OF PAYMENT – JATEKO FMG / TCM accepts Visa, MasterCard, Discover and cash payments in the office. Personal checks will be accepted.

ADDITIONAL FEES - Should you issue a check that is returned to us "UNPAID," you will receive a call from a JATEKO FMG / TCM representative asking you to come in and make the check good within 48 hours. We will collect the original check amount, bank fees determined by our bank and a $25.00 re-processing fee. Should this happen again, the bank fees increase and our second processing fee increases to $50.00. No checks will then be accepted in the future. This repayment and any future payments will be accepted in cash, credit or debit card.

COLLECTIONS - Should your account move to this status, you will receive notice to resolve your account issues within 15 days. After the fifteenth day, your status is forwarded to the three major credit bureaus. Once in collections, fees over and above the original due amount are attached to this collection process that are your financial obligation. When your account moves to this status, we will send your account to an outside collections company with all information necessary to collect unpaid balances.

MISSED APPOINTMENTS - If you are not able to keep your appointment, you must call and cancel that appointment 24 hours PRIOR to the appointment time. You must speak with the scheduler or the front desk to cancel. If you do not cancel, you may be charged a missed appointment fee. Thank you for your anticipated cooperation.

ULTRASOUND – For Ultrasound appointments, if you do not cancel by the deadline, you will be assessed an $85.00 missed appointment fee. This fee is not covered by insurance carriers or Medicare and will be your responsibility to pay at the time of your next visit. Our aim is to open otherwise unused appointments for our patients, not to collect missed appointment fees. Your cooperation and consideration are appreciated as we institute this policy.

ASSIGNMENT OF BENEFITS - All medical benefits include any major medical benefits to which I am entitled. Medicare, Private Insurance, Auto or PI Liens are re-assigned to JATEKO FMG / TCM. This assignment will remain in effect until revoked in writing by the policy-holder or patient.

A photocopy of this assignment is considered valid as an original. I understand I am financially responsible for all charges whether or not paid by my insurance company. I hereby authorize JATEKO FMG / TCM to release all information necessary to secure payment. I also understand that some services may not be covered by my medical insurance, lien, auto, PI entitlement and I will be responsible for all payments due.

(If not signed, I will pay cash visit every visit and payment will be collected at time of service.)

GUARANTEE OF FINANCIAL RESPONSIBILITY FOR PROFESSIONAL SERVICES

I understand that any eligibility for benefit coverage of professional and other services by my health plan is not a guarantee of payment for services rendered to me. I wish to receive medical services from JATEKO FMG / TCM at this time. In the event I am ineligible for benefits from a health plan, I understand that I will be fully/personally responsible for all services and supplies provided to me. I will pay all such charges when I am presented with a bill. In the event I have no health insurance coverage or I refuse to guarantee the financial responsibility, I understand that I must pay for all services rendered at the time of service. This includes insurance that may be billed out of network. It ultimately is the responsibility of the patient to know if the insurance will cover the office visit (includes in/out of network benefits).

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for JATEKO FMG / TCM to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).

(The Notice of Privacy Practices provided by JATEKO FMG / TCM describes such uses and disclosures more completely).

I have the right to review the Notice of Privacy Practices prior to signing this consent.

JATEKO FMG / TCM reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to JATEKO FMG / TCM.

With this consent, JATEKO FMG / TCM may call my home/mobile and leave a message or text on voice mail or in person in reference to any items that assist the practice in carrying out TPO. These may include (but are not limited to) all appointment reminders, insurance items, and any calls pertaining to my clinical care including laboratory test results.

With this consent, JATEKO FMG / TCM may mail to my home or other alternative location any items that assist the practice in carrying out TPO. These may include (but are not limited to) appointment reminder cards, patient statements, and any items pertaining to my clinical care including laboratory test results.

With this consent, JATEKO FMG / TCM may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO. These may include (but are not limited to) appointment reminder cards, patient statements, and any items pertaining to my clinical care including laboratory test results.

I have the right to request that JATEKO FMG / TCM restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow JATEKO FMG / TCM to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, JATEKO FMG / TCM may decline to provide treatment to me.

Release of PHI

(Protected Health Information)

By signing, I authorize JATEKO Family Medical Group (JATEKO FMG) / Talley Concierge Medicine (TCM) to release my protected health information (PHI) to the following person (example Jane Doe – Sister)

(If disclosure is requested by the patient, purpose may be listed as ‘at the request of the individual.’)
The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.
The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment from JATEKO Family Medical Group (JATEKO FMG) / Talley Concierge Medicine (TCM). In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:

JATEKO Family Medical Group (JATEKO FMG) / Talley Concierge Medicine (TCM)

3860 West Ann Rd Ste 100, North Las Vegas, NV 89031

Signed by:

Patient/guardian is entitled to receive a signed copy of this authorization form.

NOTICE OF PRIVACY PRACTICES

JATEKO Family Medical Group (JATEKO FMG) / Talley Concierge Medicine (TCM)
Effective Date: November 20, 2023

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THE PRACTICE) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI,
• Your privacy rights in your PHI,
• Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. If you have questions about this Notice, please contact: JATEKO FMG / TCM, 702-474 4110

C. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost management and business planning activities for our practices. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.

5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

6. Health-related benefits and services. Our practices may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

7. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

8. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do by federal, state or local law.

D. Use and disclosure of your PHI in certain special circumstances:

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths,
• Reporting child abuse or neglect,
• Preventing or controlling disease, injury or disability,
• Notifying a person regarding potential exposure to a communicable disease,
• Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
• Reporting reactions to drugs or problems with products or devices,
• Notifying individuals if a product or device they may be using has been recalled,
• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the • patient agrees or we are required or authorized by law to disclose this information,
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,
• Concerning a death we believe has resulted from criminal conduct,
• Regarding criminal conduct at our offices,
• In response to a warrant, summons, court order, subpoena or similar legal process,
• To identify/locate a suspect, material witness, fugitive or missing person,
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

5. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions:

(A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosures would otherwise be permitted;
(B) The research could not practicably be conducted without the waiver,
(C) The research could not practicably be conducted without access to and use of the PHI.

8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.

E. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to JATEKO FMG / TCM, 3860 West Ann Rd, STE 100, Las Vegas, NV 89031 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting restrictions. You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to JATEKO FMG / TCM, 3860 West Ann Rd, STE 100, Las Vegas, NV 89031.

Your request must describe in a clear and concise fashion:

• The information you wish restricted,
• Whether you are requesting to limit our practice’s use, disclosure or both,
• To whom you want the limits to apply.
3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to JATEKO FMG / TCM, 3860 West Ann Rd, STE 100, Las Vegas, NV 89031 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, you request must be made in writing and submitted to JATEKO FMG / TCM 3860 West Ann Rd, STE 100, Las Vegas, NV 89031, you must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to JATEKO FMG / TCM, 3860 West Ann Rd, STE 100, Las Vegas, NV 89031. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact JATEKO FMG / TCM at 702-474-4110.

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact JATEKO FMG / TCM at 702-474 4110. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies; please contact JATEKO FMG / TCM at 702-474-4110.