Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP

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1 Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP 2501 N. Orange Ave. Suite 589 Orlando, Florida Phone: Fax: Welcome to the Children s Center for Cancer & Blood Diseases at the Florida Hospital Cancer Institute. Clifford Selsky, M.D., Fouad Hajjar, M.D., Ada de la Osa, ARNP-BC, Shari Feinberg, CPON, CPOP, Kourtnie Ramirez, MSN, CPNP and all of our staff are committed to excellence and we are here to assure you that your child will have access to some of the most advanced treatment options and therapies available. Please know our doctors and staff member are here to help you if you have any questions. This packet includes information on our physicians, facility and program. It also includes important information that you will need to know about our office. Please read through the information at your leisure. Should you have any questions or concerns please do not hesitate to call our office at Sincerely, The Children s Center for Cancer & Blood Diseases Staff Florida Hospital Cancer Institute

2 Office Hours: Monday, Tuesday, Thursday, Friday from 7:30a-5:00p and Wednesdays from 9a-3p. We are closed weekends and holidays. Our physicians are on call 24 hours a day, seven days a week. If for some reason you are unable to reach our answering service please call Florida Children s Hospital at and ask to speak with the charge nurse and they will page the on call provider. Appointments: Please be aware that patients are taken back to be seen according to their appointment time. Should you arrive more than 15 minutes late for your appointment, it may be necessary for you to wait to be seen or you may be asked to reschedule your appointment. If you should arrive early for your appointment, our staff will attempt to call you back early, however, it may be necessary for you to wait until your scheduled appointment time. Though we realized it may not always be possible, please attempt to give our office at least 24 hours notice if you need to reschedule or cancel your appointment. Parents please be aware that a parent or LEGAL guardian, with appropriate proof of guardianship, must accompany your child to their appointment. This means no one without a completed MEDICAL POWER OF ATTORNEY FORM can bring your child to their appointment regardless of their relationship to the child. There will be NO EXCEPTIONS as this is a law. Prescription refills require at least hours notice. Please call our refill line at and press option #3 to leave a voic for the nurses. Laboratory and scan results can be obtained by calling and press option #3 to leave a voic for the nurses and they will return your call within 48 hours. Parking is available and complimentary for the patients of the Florida Hospital Cancer Institute. This parking area is located in front of the FHCI building, just off of North Orange Avenue. When pulling into the parking area from the Winter Park Street traffic light, please stay to the left and enter through the security gate. If there is no parking available in this lot, please be aware that there is parking available in the King Street parking garage for all Florida Hospital patients, however there is a charge for this parking. Should you have a handicap parking permit, parking is free. Please be aware that our office no longer validates parking for the King Street garage or valet parking. Insurance authorizations are required from some insurance companies. Please check with your insurance company to see if your plan requires prior authorization or a referral from your Primary Care Physician in order for you to be seen in our clinic. Also, authorization is not a guarantee of payment by your insurance company. The parent or legal guardian is responsible for any charges not paid by the insurance company. If you have any questions regarding this matter please call Jena Marmo, Office Manager at Co pays are due at the time of service. We accept cash, check, Visa, Mastercard and Discover. Change of address and phone numbers are very important. Please notify our office of any changes as soon as possible so we may contact you regarding important information about your child. Activities, toys and games are provided for your child s enjoyment. Please help us maintain a safe and clean environment by straightening up after your child before you leave.

3 2501 N. Orange Ave., Suite 589 Orlando, FL Phone Fax Patient Information This hand-out is to provide you with general information about the services provided by this office. If you have any questions about the information below, please discuss it with your child s physician or the office staff. Confidentiality Please refer to the HIPAA Form In general, the confidentiality of all communications between a patient and health care physician is protected by law. We can only release information about our work to others with your written permission. However, there are a few exceptions. Your child s physician may occasionally find it helpful to consult about his/her care with other professionals to provide optimal care. In these consultations, you child s physician will not reveal their identity and the information concerning his/her care will be kept confidential. Records Release Records of the services provided to you can only be released with your written permission. If you would like your child s records sent to any health care professional or any other party, you must complete ta Release of Information form. This form can be obtained from our office or you can provide us with a signed request for records to be sent to another party. When records are sent for continuity of care, we will send your child s evaluation report and give of the most recent treatment notes at no charge. If you would like additional records sent, you will be charged $1 per page. If you request to have records released directly to you, you will be asked to complete a Request for Access to Protected Health Information form. Often, your child s physician ill want or view these records together with you due to the fact that professional records can easily be misinterpreted. Records are $1 per page. Appointments All services are by appointment only. If you are unable to keep your child s scheduled appointment, our office requires a 24 hour cancellation notice. After 3 missed or canceled appointments, you may be discharged from our care.

4 As a courtesy, we have an automated system that reminds patients of their appointments. However, please do not rely on receiving this call to remember your appointment. Keep your appointment card in a safe place. Patient Responsibilities Making and keeping follow-up appointments is an important part of following your physician s recommendations. We believe that your child s care if a top priority and cannot provide optimal care if you do not attend your appointments regularly. Your child s physician may recommend adding other health care professionals to their treatment team. It is important that you make and keep appointments with other health care providers as recommended by your child s physician. As an active participant in your child s health care, you must agree to be responsible for following the recommendations made by his/her physician or to discuss reasons why you do not want to follow his/her recommendations. If your child has an appointment to be treated or seen by our physicians, the legal guardian must accompany the child. If the legal guardian is not available to bring the child, a notarized medical power of attorney form must accompany the person authorized by the legal guardian. Otherwise, the appointment will be rescheduled. It is the parent s responsibility to obtain insurance clearance prior to the patient s visit. If insurance cannot be approved, the child s visit may be rescheduled until insurance can be cleared. Discharge/Transfer Hematology patients may be transferred to an adult oncology practice when they reach the age of 18. Oncology patients will not be transferred at the age of 18 to be seen by an adult oncologist. Since these patients have been diagnosed with a pediatric malignancy, they will be followed and/or treated into adulthood. However, our physicians reserved the right to transfer a patient s care to a medical oncologist if it is in the best interest of the patient. The physician reserves the right to discharge a patient from our office without cause. Conduct Patients, family members and anyone accompanying the patient will not be permitted to use inappropriate behavior or language directed towards the physician or the office staff. This also applies during telephone conversations. This type of inappropriate behavior may result in discharge from this practice. Telephone Calls and Messages Physicians do not routinely accept telephone calls during clinic hours. During those times, messages can be left with the office staff or on voic . If you call is of an urgent nature, please make that clear in your message. In an emergency situation, call 911 first and then contact your physician.

5 Laboratory or x-ray results: it is your responsibility to call and review the results of your child s lab work or diagnostic testing with his/her physician. At times, our office may not be made aware of the dates when the tests were performed. Do not assume that no news is good news. If your child s physician orders tests, he or she may direct you as to the approximate time that these results may be returned to our office in order to discuss them with you. You may use this as a guide to follow up on results. After Hours Calls In the event of an after-hours emergency, please call 911 immediately. If you have a medical problem after hours, please call the office to be transferred to the answering service. If you are unable to get through to the answering service by calling the office, please call the 24-hour Florida Hospital Answering Service at Please be aware that refills will not be called in after hours. It is anticipated that your call will be returned within 20 minutes. If you do not receive a call back within that time, please call the answering service again. Insurance and Billing Prior to being scheduled for an appointment, your insurance benefits will be verified. If you are a Medicare/Medicaid recipient, we will bill Medicare/Medicaid directly, but you will be responsible for your co-payment at the time of your visit. Please be sure to inform us if you have a secondary insurance policy. Services will not be provided on the basis of a lien. If you would like to submit your insurance claims directly to your insurance company, you will be responsible for the total fee of services rendered at the time of your visit. We can provide you with a paid receipt that you can submit for reimbursement. If you do not utilize an insurance benefit, you will be responsible for the total fee for services rendered at the time of your visit. Co-payments are due at the time of service. If you are unable to make a co-payment, then your appointment may be rescheduled. You will receive a bill from our corporate office, Florida Hospital Medical Group (FHMG). If you carry an account balance, it will be important that you make regular payments each month whether insurance he s paid or not. Balances over 60 days will be subject to a 1.5% interest charge to cover the costs of carrying the account and continued billing per FHMG policy. You are responsible for any charges not covered by your insurance company. Additionally, you are responsible for any costs incurred should collection proceedings be required. These are generally started if no payment has been made on the account after 90 days. Finally, many insurance companies require that we send diagnostic and clinic information along with bills and requests for services. Whereas such information is confidential and generally treated as such by insurance carriers, we cannot guarantee how any particular insurance carrier or employer will handle this information. There may be times when your physician needs to order specific laboratory tests or is requesting STAT results from our Florida Hospital Lab. Depending on your insurance plan Florida Hospital Lab may not be

6 in network and therefore they may not cover services provided by Florida Hospital s Lab. Our office staff will do our best to obtain prior authorization for any services needed. However, we may not always be able to get authorization from your insurance company. Please understand that any services not covered by your insurance company will be your responsibility. Authorizations provided by your insurance company do not always guarantee payment. These charges will be the patient/parent responsibility. Non-Covered Services There may be times when you need your physician to complete forms that are not related to your treatment (e.g., disability paperwork, etc). Due to the additional time that is takes to complete these forms outside of your appointment times, you may be charged an additional fee. Our physicians are sometimes asked to write a letter to a person or agency that is not directly related to your child s treatment. The charge for this type of service is $ This fee will be billed directly to you. You are your child s best advocate and you have to be an integral part of your child s medical care. Our physicians and office staff are dedicated to making your visit to our office a positive experience and look forward to working with you as a team.

7 Patient Information Packet Acknowledgement I,, have received the Patient Information packet. I have read the packet or have had it read to me. I understand it is my responsibility to review my questions with my physician. I understand policies on the following: Confidentiality Please refer to HIPAA Form Records Release Appointments Patient Responsibilities Discharge/Transfer o Conduct Telephone Calls and Messages After Hours Calls Insurance and Billing o o Co-payments Out of Network Labs Non-covered services I have received a signed copy of this document. Patient or Guardian Signature Witness Date Date