New Patient Forms
Ambulatory Surgery Center Forms
Release of Information
- Authorization to Release PHI –to- IPMR
- Authorization to Release PHI –from- IPMR - English | Spanish
- Consent for Others to View Personal Health Information
Appointments: Please call 208-884-1333 to make your appointment. You will receive a courtesy reminder call two days before your appointment. If you can’t keep your appointment, please give us 24 hours’ notice so you can be rescheduled for a more convenient time.
Office Hours: We’re open Monday - Thursday 8am - 5pm and Fridays 8am - 4pm. We are closed most major holidays. If you have an emergency medical issue, please contact your nearest emergency care provider. If you need to contact one of our providers after hours, please call 208-884-1333, and you will be connected to our answering service.
Telephone Calls: If you need to speak directly with your IPMR provider, please consider that he/she has commitments to patient schedules that sometimes makes it difficult to return calls during regular office hours. Our staff will document your concerns/requests and forward them to your provider. Our Patient Portal allows you to message your provider any time of day. The provider will get back to you during business working hours.
Prescription Refills: Please contact your pharmacy to request a refill for your medication. The pharmacy will send the request to our office. If you are taking a medication that requires a paper prescription to be picked up in the office, please contact our office directly. It is your responsibility to anticipate your medication refill needs. Please allow three business days for processing medication refill requests.
Payment Policy: Payment (or co-payment) is expected at the time of service, unless other arrangements have been made. We will file insurance claims for you; however, you are directly responsible for your account. Federal laws require that we submit insurance claims to accurately reflect the services performed.
Online Bill Pay
With the Patient Portal, you will have access to:
- Appointments – Keep Track of appointments
- Lab Results – Access and view lab results
- Medication – Request prescription refills
- Medical Records – View your personal health record
- Education – Receive educational materials
- Messages – Send & receive messages from staff and providers
- Demographic Information – Update demographic information
Surgery Center Policy
PRACTICE POLICIES AND PROCEDURES ADVANCE DIRECTIVES and “DO NOT RESUSCITATE” in the ASC
Original Issue Date: 7/2009
Revision Dates: 10/1/09
POLICY TITLE: ADVANCE DIRECTIVES
POLICY: Patients generally have a right to execute advance directives and have those directives honored; however, for moral and professional reasons, IPM&R/Ambulatory Surgery Center (ASC) will take reasonable action to stabilize or revive patients who have suffered a life threatening condition, including the use of CPR or other artificial life sustaining treatment. Accordingly, IPM&R/ASC will not honor advance directives to the extent that such directives would otherwise prohibit life sustaining treatment.
1. Advance Directives. Patients generally have the right to make informed decisions concerning their treatment. Advance directives are written instructions that declare a patient’s treatment decisions or appoint a representative to make treatment decisions for the patient if the patient becomes incapacitated. Idaho statutes recognize the following forms of advance directives:
a. Living Will. A living will allows a patient with a terminal condition to specify certain treatment options if the patient becomes incapacitated, including the withdrawal or withholding of certain types of life sustaining treatment. Idaho Code § 39-4510 to -4514 sets forth the requirements for valid living wills.
b. Durable Powers of Attorney for Health Care. A durable power of attorney for health care appoints a personal representative who may make health care decisions for the patient if the patient becomes incapacitated. Idaho Code § 39-4510 to -4514 sets forth the requirements for a valid durable power of attorney.
c. Physician’s Orders for Scope of Treatment (“POST”). A POST is a physician order executed on a standardized form issued by the state of Idaho that directs the care to be provided to the patient under certain circumstances, including the withdrawal or withholding of life sustaining treatment. Idaho Code § 39-4511 to -4514 sets forth the requirements concerning POSTs. If a patient requests a POST, their physician must help the patient complete the POST and periodically review the POST. Once completed, a valid POST is effective in any facility. See I.C. § 39-4512A to -4514.
d. Do Not Resuscitate Orders (“DNRs”). DNRs are physician orders that specify treatment to be provided in the event that the patient suffers a life threatening condition.
e. Other Advance Directives; Technical Defects. Although the foregoing are the advance directives expressly recognized by statute, Idaho law confirms that they are not the only way to effectively communicate a patient’s treatment wishes. I.C. § 39-4509. Any authentic expression of a patient’s lawful treatment wishes should be honored. Id. Accordingly, IPM&R physicians may honor advance directives that clearly document the patient’s wishes even if they contain technical defects.
2. Resuscitation; No “Do Not Resuscitate” Directives. Idaho allows physicians to decline to honor a living will, POST, or other advance directive due to ethical or professional reasons. I.C. § 39-4513(2). It is IPM&R’s ASC policy to take reasonable action to revive patients who have suffered a life threatening condition, including the use of artificial life sustaining treatment. Accordingly, IPM&R Ambulatory Surgery Center will not honor advance directives to the extent that such directives would otherwise require the withholding or withdrawal of such life sustaining treatment, including POSTs and living wills.
3. Written Notice to Patients. Consistent with federal requirements, IPM&R will provide written notice to ASC patients concerning their right to execute advance directives and IPM&R’s/Ambulatory Surgery Center’s policy concerning advance directives, including IPM&R’s/ASC policy not to honor directives for the withholding of life sustaining treatment. Such notice shall be provided prior to obtaining informed consent for treatment. Such notice shall be provided so that the patient receives and may review the policy at least one day prior to any scheduled ASC procedure.
4. Advance Directive Forms. If the patient requests a copy of Idaho’s approved POST or living will/durable power of attorney form, state laws and federal regulations require that IPM&R provide the forms to the patient. The living will/durable power of attorney form is located in Idaho Code § 39-4510, which can be accessed at http://www2.state.id.us/ag/living_wills/LivingWill_DurablePowerOfAttorney.pdf. The POST form is available at www.sos.idaho.gov/general/hcdr.htm. To request a password to obtain the POST form, send an e-mail with the physician or facility name and license number to email@example.com. Idaho law requires that the attending physician assist the patient with completing a POST form. See I.C. § 39-4512A. For more information on POST form requirements or completing the POST form, see the attached POST Form Instructions for Physicians.
5. Documenting Advance Directives. IPM&R must document the existence of any advance directives in the patient’s medical record. The documentation must be placed in a prominent part of the medial record where it will be readily noticeable by clinical staff providing services to the patient. If a patient in the ASC is transferred to another health care facility (e.g., if there is an emergency transfer to a hospital), the ASC must ensure a copy of the advance directive is sent with the medical record.
6. Patient With Advance Directive That Prohibits Life Sustaining Treatment. If the patient presents with an advance directive that requires life sustaining treatment contrary to IPM&R/ASC’s policy, IPM&R personnel must explain IPM&R’s/ASC policy to the patient and do the following:
a. Document Consent to Life Sustaining Treatment. If the patient agrees to waive or suspend operation of the advance directive, IPM&R/ASC personnel shall document in the medical record that they discussed IPM&R’s policy with the patient and that the patient consents (1) to receive life sustaining treatment consistent with IPM&R’s/ASC policy, and (2) to waive or suspend the conflicting provisions in the advance directive.
b. No Consent; Referral to Another Provider. If the patient will not consent to life sustaining treatment and/or will not waive or suspend the conflicting provisions of their advance directive, IPM&R/ASC personnel shall explain to the patient that they cannot provide treatment to the patient; shall make a good faith effort to assist the patient in transferring their care to another willing provider; and shall document the circumstances and communications in the patient’s record.
Effective Date: August 1, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. | View Spanish Version Here
We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164. We are required to abide by the terms of our Notice that is currently in effect.
1. Uses And Disclosures We May Make Without Written Authorization. We may use or disclose your health information for certain purposes without your written authorization, including the following:
Treatment. We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer.
Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain pre-authorization or payment for treatment.
Healthcare Operations. We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use information to train or review the performance of our staff or make decisions affecting the practice.
Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by 45 CFR § 164.512 or other applicable laws and regulations, including the following:
- To avoid a serious threat to your health or safety or the health or safety of others.
- As required by state or federal law such as reporting abuse, neglect or certain other events.
- As allowed by workers compensation laws for use in workers compensation proceedings.
- For certain public health activities such as reporting certain diseases.
- For certain public health oversight activities such as audits, investigations, or licensure actions.
- In response to a court order, warrant or subpoena in judicial or administrative proceedings.
- For certain specialized government functions such as the military or correctional institutions.
- For research purposes if certain conditions are satisfied.
- In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes.
- To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties.
2. Disclosures We May Make Unless You Object. Unless you instruct us otherwise, we may disclose your information as described below.
- To a member of your family, relative, friend, or other person who is involved in your healthcare or payment for your healthcare. We will limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.
3. Uses and Disclosures With Your Written Authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes; for most marketing purposes; or if we seek to sell your information. You may revoke your authorization by submitting a written notice to the Privacy Contact identified below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
4. Your Rights Concerning Your Protected Health Information. You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below.
- You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer.
- We normally contact you by telephone or mail at your home address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests.
- You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy. We may charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances, e.g., if we determine that disclosure may result in harm to you or others.
- You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete.
- You may receive an accounting of certain disclosures we have made of your protected health information. You may receive the first accounting within a 12-month period free of charge. We may charge a reasonable cost-based fee for all subsequent requests during that 12-month period.
- You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically.
5. Changes To This Notice. We reserve the right to change the terms of this Notice at anytime, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the operative Notice from our receptionist or Privacy Officer.
6. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.
7. Contact Information. If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above, please contact:
Compliance & Privacy Officer
Phone (208) 489-4016
Fax (208) 489-4015
P.O. Box 1128 Boise, ID 83701
NOTICE OF POLICIES, PATIENT RIGHTS AND PATIENT RESPONSIBILITIES - Read Spanish Version Here
- To be treated with respect, consideration and dignity, and to be free from all forms of abuse or harassment by staff, other patients, or visitors.
- To receive, to the degree known, complete information concerning their diagnosis, evaluation, and prognosis, and to be fully informed about contemplated treatment or procedures and the expected outcome before the treatment or procedure is performed.
- To participate in decisions involving their health care and to make informed decisions concerning their treatment before the treatment is performed, except when such participation is not medically appropriate.
- To execute advance directives concerning the patient's treatment preferences consistent with Idaho law and to have those directives honored subject to the limitations described below.
- To change the patient's physician or practitioner if other qualified physicians or practitioners are available.
- To receive treatment in a safe setting.
- To reasonable privacy during the patient's treatment, including during personal hygiene activities, during medical/surgical treatments, or when otherwise requested as appropriate.
- To confidentiality of the patient's health information, and to access and exercise certain other rights concerning the patient's health information, as more fully described in IPM&R's Notice of Privacy Practices.
- To exercise the patient's rights without being subject to discrimination or reprisal.
- If the patient is deemed incompetent under Idaho law, to have treatment decisions made and patient rights exercised by the patient's legally authorized representative.
- To make suggestions, complain or submit a grievance relating to the patient's care by contacting: ATTN: State Agency Representative, Bureau of Facility Standards, Non - Long Term Care Co-Supervisor You may also report complaints to the Idaho Bureau of Facility Standards @ 3232 Elder St., Boise, Idaho 83705, (208) 334-6626 or www.facilitystandards.idaho.gov, and/or the Office of the Medicare Beneficiary Ombudsman, (800) 633-4227 or www.cms.hhs.gov/ombudsman/resources.asp.
PATIENT RESPONSIBILITIES: In addition to rights, IPM&R patients and their legally authorized personal representatives also have certain responsibilities to assist us in providing effective care. By consenting to treatment at IPM&R, you agree to the following:
- To provide accurate and complete information concerning the patient's health, including present complaints, past illnesses, hospitalizations, medications (including over the counter products and dietary supplements), allergies, sensitivities, and other matters relating to the patient's health.
- To report unexpected changes in the patient's condition to the patient's physician or other practitioner, including but not limited to complications following surgery.
- To ask questions or notify the physician or practitioner if you do not understand or need information relating to the patient's care or treatment.
- To notify IPM&R if the patients has executed any advance directives, e.g., a living will, durable power of attorney, physician's order for scope of treatment ("POST"), or similar document.
- To keep appointments and notify IPM&R at least 24 hours in advance when the patient is unable to do so.
- To comply with the treatment plan and instructions from the patient's physician or practitioner relating to the patent's care or treatment, including but not limited to pre- and post-operative instructions.
- To accept responsibility for the consequences if you refuse recommended treatment or fail to comply with directions and instructions relating to the patient's care or treatment.
- If the patient is a surgical patient, to provide a responsible adult to transport the patient to and from IPM&R and to remain with the patient for 24 hours following surgery unless otherwise directed by the physician.
- To be considerate, treat IPM&R staff, patients, and visitors with courtesy, and avoid conduct that is disruptive, disrespectful, or interferes with care rendered at IPM&R.
- To be responsible for the patient's personal property, and to respect the personal property of IPM&R and other patients or visitors.
- To read and understand all notices, consents and other documents relating to the patient's treatment or IPM&R's policies, and to ask questions if you do not understand such documents.
- To comply with IPM&R policies and rules concerning patient care, conduct, and payment for services rendered by IPM&R.
- To ensure that payments for services rendered by IPM&R are made in a timely fashion, and to accept ultimate financial responsibility for the services rendered by IPM&R regardless of the insurance that the patient may have, including responsibility for any costs that are not covered by applicable insurance.
- To notify IPM&R if you have a question, concern, or complaint about your care at IPM&R or IPM&R's policies or practices.
ADVANCE DIRECTIVES: Competent patients may execute advance directives which document the patient's treatment preferences or appoint a representative to make decisions for the patient if the patient becomes incapacitated. See Idaho Code § 39-4509 et seq. Advance directives include living wills, durable powers of attorney, and physicians' orders for scope of treatment ("POSTs"). IPM&R will make a copy of Idaho's living will/durable power of attorney or POST form available upon request; however, IPM&R recommends that you seek competent legal advice when considering such forms. IPM&R's policy for advance directives is as follows:
- In General. IPM&R will generally honor a patient's documented advance directive of which IPM&R has notice to the extent that such advance directive is consistent with applicable law and is medically appropriate, except as otherwise provided below.
- No "Do Not Resuscitate" Directives. For ethical and professional reasons, it is IPM&R's policy to take medically appropriate measures to revive or stabilize a patient who may suffer a life threatening condition at IPM&R, including but not limited to using cardiac life support procedures or other life sustaining treatment, and transferring the patient to an appropriate hospital for further treatment. Accordingly, IPM&R will not honor POSTs, Do Not Resuscitate ("DNR") Orders, or other advance directives to the extent that such directives prohibit life sustaining treatment. By consenting to treatment at IPM&R, you consent to such life sustaining treatment, and you waive or suspend any contrary directions in any advance directives. If you are unwilling to consent to life sustaining treatment, you must notify IPM&R immediately so that the patient's care may be transferred to another appropriate provider.
DISCLOSURE OF OWNERSHIP INTERESTS: The following physicians have an ownership or financial interest in IPM&R's ambulatory surgery center: Robert H. Friedman, M.D., Nancy E. Greenwald, M.D., Christian C. Gussner, M.D., Monte H. Moore, M.D., Barbara E. Quattrone, M.D., Mark J. Harris, M.D.