Contact Us
(909) 985-5562
Monday - Friday 9a - 6p
Areas We Serve:
Orange County
LA County

Coming soon to:
Inland Empire and Riverside County

Terms and Conditions

Mobile Phlebotomy Services, Inc.

Agreement Form

 

Mobile Phlebotomy Services, Inc. (MPS) is responsible for the drawing and handling of laboratory specimens. MPS does not collect any specimens without a physician order or a request from a laboratory. Mobile Phlebotomy Services, Inc. is not permitted to give any medical advice, treat or diagnose anyone.

 Mobile Phlebotomy Services, Inc. handles the delivery of all samples to their proper laboratory. If the specimen has special handling we will package all specimens for pick-up via courier at the patient’s home. Under no circumstances will a client be given a sample to handle. MPS is not responsible for any delay of arrival to the laboratory, due to weather conditions or any other problems that may occur once the sample has been delivered or picked up by courier service.

 Mobile Phlebotomy Services, Inc. is not responsible for any errors that may occur at the laboratory. Any errors in collection caused by MPS will be corrected by re-drawing at no additional charge. MPS makes every attempt to have contact with the patient’s prior to the draw. We do not go out unless we have made verbal contact with the patient the night before or morning of the scheduled blood draw. If we arrive at the appointment for the blood draw and are unable to collect the specimen due to circumstances beyond our control (the patient refuses, is not available to be drawn etc.) the patient will remain responsible for the full charges of the draw. Any errors in collection caused by MPS (drawing the wrong tubes, unable to obtain a satisfactory blood flow to collect the specimen etc.) will not incur a charge to the patient or will be redrawn at no additional charge to the patient.

Payment for our services is due on the date of service. Mobile Phlebotomy Services, Inc. does not bill insurance companies; any claims must be submitted by the client. Mobile Phlebotomy Services, Inc. is an independent phlebotomy service. MPS does not have any ties to any laboratories or doctor’s offices. Under no circumstances will Mobile Phlebotomy Services, Inc. divulge client information, personal or other, to any authorized personnel. All clients’ information is always kept confidential. We are fully HIPAA compliant and respect the privacy of the individuals we serve.

I understand the above terms and conditions.

 

 

 

 ___________________________________________

Print Name        

 
 

__________________________________/__________

Signature                                  Date

Notice of Mobile Phlebotomy Services, Inc. (MPS) Privacy Practices

  

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.

MPS respects your privacy and understands that your personal health information is sensitive. According the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we cannot disclose your “protected health information” to others unless we have your permission – or unless the law authorizes or requires us to do so. The Health Information Technology for Economic and Clinical Health (HITECH) Act also requires us to notify you when the security or privacy of your health information is breached. Depending on the type of breach and how many individuals are affected, this may also involve notifying the media and/or government enforcement agencies, and keeping a log of all breach incidents.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

 

Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Mobile Phlebotomy Services, Inc.. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

 

Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use of disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use of disclosure of information that occurred before you notified us of your decision.

Additional Uses of Information

Individual Rights

You have certain rights under the federal privacy standards. These include:

·         The right to request restrictions on the use and disclosure of your protected health information

·         The right to receive confidential communications concerning your medical condition and treatment

·         The right to inspect and copy your protected health information

·         The right to amend or submit corrections to your protected health information

·         The right to receive an accounting of how and to whom your protected health information has been disclosed

·         The right to receive a printed copy of this notice

MPS Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information

As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the office. Please make all requests through Lysa Giles.

Complaints/Contact Person

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

 

                                                Nancy La Salle

Administration and Quality Control Director

                                                Mobile Phlebotomy Services, Inc.

                                                757 Cabot Ct.

                                                Upland, CA 91784

                                                909.985.5562

 

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.  You will not be penalized or otherwise retaliated against for filing a complaint.

 

Effective Date

This Notice is effective on or after June 2003.