General Consent to Treat

You consent to reasonable and necessary medical exams, testing, and treatment by OrthoVirginia, Inc. (OV) and its physicians and providers. You understand that those participating or observing your care may include resident physicians and students or other trainees. You have the right to decline students or observers participating in your care by informing OV staff of your wishes. You are aware that the practice of medicine (including surgery) is not an exact science, and no guarantee is made about the results of your treatments, exams, or procedures. You may be asked to sign other informed consent forms for specific surgeries or procedures.

Patient Rights and Responsibilities

Patient Rights. As an OV patient, you have the right:

• To courtesy, respect, dignity, and attention to your needs.
• To receive information necessary for informed consent, including the specific procedure/treatment, significant medical risks, and probable duration of recovery.
• To have the opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing or not complying with treatment or therapy.
• To be provided, as best known, with information concerning diagnosis, treatment and prognosis.
• To ask questions and receive answers about your health or recommended treatment.
• To make decisions about recommended care and to have those decisions respected, except when medically unadvisable. A patient who has decision-making capacity may accept or refuse any recommended medical treatment.
• To additional care when medically necessary, including your physician’s cooperation in coordinating care with other providers.
• To not have your care discontinued except as permitted under Virginia law.
• To know the names and professional status of individuals providing service to you and to know the physician primarily responsible for your care.
• To have the physician and other staff respect your privacy and confidentiality and to expect that all disclosures, communications, and records are treated confidentially in accordance with applicable law.
• To obtain copies or summaries of your medical records, including access to a 24/7 patient portal, MyChart, and to have the information explained or interpreted as necessary, except when restricted by law.
• To obtain a second opinion and to be informed of your right to change providers if other physicians are available to meet your needs.
• To choose the facility of your choice for all procedures and ancillary services. OrthoVirginia physicians have an ownership interest in OrthoVirginia, and further interests are discussed below.
• To receive services without regard to race, color, age, gender, sexual orientation, religion, marital status, handicap, national origin, or sponsor.
• To be provided reasonable physical access to our facilities and to be provided with a safe environment.
• To receive services in a language you understand or via methods of effective communication through access to qualified foreign language and ASL interpreters.
• To be informed of key information and policies, including those addressing treatment for unaccompanied minors, expected conduct and responsibilities of patients, services offered, information on after hours and emergency care, fees for services, payment responsibilities, right to refuse participation in research studies or clinical trials, how to file a complaint or express a grievance without retaliation, and ownership disclosure.

Patient Responsibilities. As an OV patient, you have the following responsibilities:

• To behave in a respectful and considerate manner towards all patients, families, visitors, health care personnel, and OV property and facilities.
• To provide accurate and complete information about your medical conditions, health history, demographics, and insurance coverage, and to provide updates when this information changes.
• To ask questions and seek clarification until you fully understand.
• To accept the outcome if you should refuse a treatment or procedure, or if you do not follow the plan of care given by the physician or other health care providers.
• To keep or cancel appointments and notify OV of needed changes.
• To assure that the financial responsibilities for your care are paid.
• To be responsible for valuables that you bring to OV facilities.
• To provide positive and/or negative feedback in a constructive and appropriate manner about the care you have received at OV.
• To follow the policies, rules, regulations, and procedures of OV.

If you fail to follow medical instructions, display disruptive behavior or have others accompanying you who display disruptive behavior, cancel or do not show for three or more appointments, or fail to remain current on your payments, OV may terminate the patient/provider relationship.

Patient Financial Responsibility

A copayment is a fixed amount established by an insurance plan for sharing the cost of certain health services. Copayments are predetermined and should be outlined in your health insurance plan. It is your responsibility to understand your coverage guidelines, potential copayments, and information such as:

• If your insurance requires a co-pay, OV expects to collect it on your visit date.
• Prior balances will be collected at check-in, unless a payment plan has been established and is current; otherwise, OV reserves the right to reschedule your appointment. 
• If OV does not participate with your insurance plan or your plan does not cover certain treatment, you may be responsible for higher out of pocket costs for services.

Personal Injury/Accidents

If you have sustained an injury as a result of an accident, OV will file claims with your personal health insurance company. If claims are denied by your personal health insurance, an itemized statement will be provided so that you may file directly to the third-party liability insurance carrier that may be covering the accident (automobile, homeowners, accident, etc.)

Patient Financial Agreement

You agree that it is your responsibility to provide OV with current and correct insurance information and consent to OV billing your insurance company, Medicare, Medicaid, Tricare, or any other third-party payer (each a “Payer” and together, “Payers”), as applicable, directly for services rendered, and you further consent to the payment of medical benefits by your Payer to OV and associated medical providers. You also agree to provide the aforementioned information at the time of service or within 30 days from the date of service, failure to do so can result in higher out of pocket costs for services. You understand that it is your responsibility to secure all necessary prior approvals, authorizations and referrals as required by your Payer(s).

You hereby authorize OV to release any health information to any and all applicable Payers and appropriate third parties as determined by OV for eligibility and payment purposes. This release will be considered valid until revoked by you in writing. You authorize any holder of medical or other information about you to release to Medicare and its agents any information needed to determine available insurance benefits.

If your treatment is resulting from a work-related injury or accident, you must notify OV immediately. Also, you must provide complete information about the Workers’ Compensation (WC) insurance for your case. Services provided for work-related injuries must have an approved authorization prior to treatment. If services are subsequently denied due to inaccurate or missing information and there is no alternate health insurance coverage to submit claims to, you will be held responsible for any balances.

If it is pre-determined you will have any financial responsibility, OV may require a deposit prior to service. If the deposit is not received in full, OV reserves the right to delay and/or cancel any non-emergent services until financial arrangements can be determined/met. Full payment is required within thirty (30) days of receiving your billing statement. You agree you are financially responsible for all charges made to your account whether or not a Payer or attorney is involved. You are responsible for all copayment and co-insurance amounts, non-covered supplies and services, and annual deductibles.

If you have an outstanding balance due, you agree to a prompt payment in full. If you are unable to pay in full, you can contact OV’s billing department at 844-493-7933 for possible payment arrangements. In the event your account is turned over to a third-party collection service, you grant authorization for information to be released regarding your employment status to OV or to the collection agency and/or collection attorney.

If you are financially responsible for a patient account and the account is sent to a collection agency and/or collection attorney, you agree to pay, in addition to all other amounts you owe, any and all costs of collection including, without limitation, an attorney fee equal to one-third (1/3) of your outstanding balance and other costs associated with collection. If any balance due is not paid in full within 60 days from the date of service, you agree to pay interest at a rate of 1.5% per month [18% per annum]. You also agree to pay any credit/debit card and/or transaction fees required to be paid by the collection agency or attorney’s law firm, should you choose to pay your debt by those means. All returned checks will incur a returned check fee of $50.00.

If you are without health insurance at the time of service, OV may offer a discount to your charge(s). Payment of the reduced amount must be received within 30 days from the date of service.  If payment is not received by OV within that time the discount will be revoked, and you will be responsible for the full amount of any outstanding charges.

OV reserves the right to charge a fee for a cancellation of less than 24-hour notice or failure to keep an appointment (i.e. no showing a scheduled appointment).

Notice of Financial Interest

OV offers services and products to patients which provide appropriate methods for treating musculoskeletal issues. OV and its individual providers have a financial interest in these services and provide them for your convenience. These services include the following:

• Boulders Ambulatory Surgery Center, 1115 Boulders Pkwy, Suite 210, Richmond, VA 23225
• Bremo Operatory, 5899 Bremo Road, Suite 100A, Richmond, VA 23226
• Shrader Operatory, 7858 Shrader Road, Richmond, VA 23294
• Herndon Operatory, 13350 Franklin Farm Road, Suite 100, Herndon VA 20171
• McLean Tysons Orthopedic Surgery Center, 1760 Old Meadow Road, Suite 100, McLean, VA 22102
• Surgery Center of Lynchburg, 2401 Atherholt Road, Lynchburg, VA 24501
• Procedure suites in multiple locations. Please see www.orthovirginia.com/locations
• X-ray imaging at all OV locations.
• Physical and Occupational therapy services in multiple locations. Please see www.orthovirginia.com/locations
• MRI imaging centers at the Johnston Willis, 400 Johnston Willis Dr UNIT A, Richmond, VA 23235, Henrico Parham, 7650 E Parham Rd # 100, Richmond, VA 23294, Lynchburg, 2405 Atherholt Road, Lynchburg, VA 24501, and Tysons Corner, 8320 Old Courthouse Road, Suite 150, Vienna, VA 22182
• DME and bracing services within OV offices.

OV feels these services offer quality and value, but you have the right to choose where you will receive these services. If you prefer to choose another option, let our staff know and OV will work with you in providing alternate and appropriate solutions.

Medication Prescription Policy

1. Each prescription will be for a fixed amount of medication. You should take the medication exactly as prescribed. Medication will not be increased or renewed early unless the provider feels it is appropriate to do so.
2. Telephone calls for prescription refills will only be renewed by the treating provider during business hours. The on-call physician after hours will only entertain telephone calls regarding adverse reactions to your medications. Please note medication refill requests may take 48 business hours to complete.
3. We participate with, and may review, the Commonwealth of Virginia Department of Health Professions (DHP) Prescription Monitoring Program (PMP). If there is evidence of prescription pain medicines being obtained or requested from another provider, you will not be able to request or obtain those prescriptions from our providers.
4. In following with the Board of Medicine’s requirements (18 VAC 85-21-10 et seq.) for treating chronic pain (pain lasting longer than 3 months) all physicians will be required by state law to obtain urine drug screens or serum medication levels at the initiation of chronic pain management and randomly thereafter at the discretion of the practitioner but at least once a year. Patients being treated for chronic pain may be required to complete a pain medication contract.
5. Appointments must be kept or cancelled 24 hours prior to the scheduled time, for medications to be extended. Medications may be discontinued due to repeated cancellations or failing to show for appointments. It is important that you keep your scheduled follow-up visits so that your provider can monitor your treatment.
6. It is your responsibility to prevent loss of prescriptions or medications. Do not expect lost or stolen prescriptions or medications to be replaced, regardless of the situation. A police report is required for all claims of theft.
7. In the interest of your physical well-being, it is strongly recommended that you be under the care of a primary care physician.
8. You may be asked to actively participate in other recommended treatments such as physical therapy, home exercise program, procedures, testing, and/or other medications. If you are unable to participate you will need to make your provider aware of any reasons that prohibit participation. You must keep us informed of any changes in your condition such as pregnancy, change in provider, change of pharmacy, and Emergency Room visits.

There are limitations and side effects of pain medications including but not limited to sedation, dizziness, drowsiness, nausea, vomiting, constipation, physical dependence, tolerance, respiratory depression, overdose, and even death.

Any deviation from this policy is at the sole discretion of the prescriber and does not guarantee future deviations. Violation of any of the above can result in discontinuation of medication prescriptions and possible discharge from OV.

Deemed Consent for Blood Sample Withdrawal and Testing

Under Code of Virginia § 32.1-45.1, you consent to the withdrawal of a blood sample from yourself, your child, or an individual over whom you have guardianships’ body, in the event that an OV employee or physician sustains an exposure to the aforementioned’ s blood or body fluid. You agree to follow OV staff member instructions about where to go to get your blood drawn after exposure.  If the exposure occurs in an OV Operatory or Pain Management, you agree to the immediate collection of a blood sample by the Operatory staff. You agree to the testing of the blood sample for human immunodeficiency virus (HIV), hepatitis B, and hepatitis C, at no cost to you, and to the release of the test results to the exposed employee and provider(s) treating them.

Electronic Health Record and Patient Portal Acknowledgement

Epic is OV’s electronic health record.  OV uses Epic to create an electronic chart with your health information, including but not limited to your office notes, x-ray images, and a record of your encounters.  You authorize OV to use the Epic electronic health record to electronically send and receive PHI pertinent to your care. This includes texts, images, and x-ray files.

OV offers a patient portal, MyChart, to its patients, for access to health information about themselves, to request appointments, and to send communications to OV staff and providers.  It is vital to your care to enroll in MyChart; by doing so, you give OV permission to send your health information through MyChart for your personal access and use, including messaging, images, and x-ray files. Please review the MyChart Terms and Conditions at the bottom of the MyChart website. Uses and disclosures of information in MyChart by OV are governed by the Notice of Privacy Practices and federal and state privacy laws.  If you wish to terminate access to MyChart, you can contact OV by sending a message via MyChart, or you can call our MyChart Patient Support Line at 1-877-701-6088.

Email Address

OV highly encourages patients to provide their email address so that we may serve you better.  We use e-mail to send appointment reminders, surveys, MyChart activations, and notifications to you about our practice. If you subscribe to MyChart, MyChart will send you email notifications about appointment reminders, test results, payment due, etc.  Your e-mail address is a part of your protected health information and will only be used in accordance with our Notice of Privacy Practices. If you provide us with your email and later decide you would like to unsubscribe, you may let us know by sending a message via MyChart or calling our MyChart Patient Support Line at 1-877-701-6088, and we will remove your email address from our electronic health record.

Our policies require us to email health information to you encrypted or via MyChart.  If you ask us to send unencrypted email, that email will not be secure. Unsecure emails may be viewable by others while being sent or while maintained in your inbox.  You must provide us with a statement in writing (e.g., letter, email, MyChart message) that you do not want email with your health information to be encrypted.  You understand that if you ask us to send an unsecured email, you are assuming this risk.

Telephone Calls and Text Messages

OV collects residential and cellular telephone numbers provided to us and may use these numbers to communicate with you about your treatment, your appointments, or procedures, to service your account, or to collect any amounts you may owe.  If we contact you by cell phone number, this could result in charges to you. We may also leave a message on voicemail in reference to any items that assist the practice in carrying out treatment, payment or our internal operations, such as appointment reminders, insurance items, and any call pertaining to your clinical care, including laboratory results.

Certain text messages containing minimal information may be sent via an automated texting service or two-way communication platform to your cell phone.  For example, we may text you automated appointment reminders, prompts to sign up for MyChart, the availability of test results, that a new balance is due for payment, or a new bill is available in MyChart, or requests to provide feedback about our services. We may also contact you via a secure platform that allows for two-way communication about your upcoming visit, check-in, or payment due. You agree that OV or its vendors may contact you as described above.  To unsubscribe from any automated phone/text messaging, send a message via MyChart or call our MyChart Patient Support Line at 1-877-701-6088.

Patient Satisfaction and Outcome Surveys

You agree to receive a patient satisfaction survey after a visit to our office. We encourage you to complete it as we use this feedback to educate our team on how we are doing. You are important to our practice and your feedback will help ensure we continue recognizing areas of opportunity that will improve your overall patient experience with us! You also agree to receive a series of outcomes surveys just before and after common orthopedic surgical procedures. You may receive the survey by mail, email, by text message, or telephone call as described above. Outcomes data is the cornerstone of assuring that our patients receive quality care, so please complete these surveys. OV compares your responses anonymously to national databases to benchmark the quality of care we provide. Thank you in advance for taking the time to complete the surveys.

Clinical Research

OV conducts research with the aim of continuing to advance medical knowledge and provide the best possible care to our patients. Your medical information may be used for research purposes, and you may be asked to participate in a research study. You have the right to:

1. Informed Decision: you have the right to clear explanations about any prospective research using your data or samples, including its purpose, risks, and benefits.
2. Right to Opt-Out: you can choose not to participate in any retrospective or prospective research. This choice won’t impact your quality of care.
3. No Retaliation: you will not face discrimination or reprisal for opting out, ensuring an unchanged relationship with your healthcare provider.
4. Data Protection: if you choose not to participate in any retrospective of prospective research, your related data or samples will be promptly removed and destroyed, with the option for confirmation upon request.
5. Continuous Consent: You can change your participation choice at any time, with mechanisms in place for updating preferences.
6. Transparent Communication: Should any research changes occur that might influence a patient’s decision, they have the right to be informed and reevaluate their participation.

We encourage you to seek clarity on research participation to ensure your decisions align with your preferences. Should you choose not to participate in any retrospective or prospective research, you may opt-out through OV’s patient portal, MyChart, or by informing OV staff of your wishes.

Acknowledgement and Acceptance of Policies and Procedures

I acknowledge that I will be asked to agree to the above stated policies and practices of OV during registration.

Contact

If you have any questions about the Statement of Practice Policies, please reach out to: [email protected] or call 804-486-6856 and someone will return your call.

Changes to this Statement

OV reserves the right to update the practice policies contained in this Statement of Practice Policies at any time.  OV will make any revised Statement available on its website and in each office location on or after the effective date of the changes. The updated date below may not be earlier than the date the revised Statement is printed or published.

Updated July 24, 2020; August 1, 2024