Phatak & Labuzetta Physicians, PLLC

P.O. Box 23231

Rochester, NY 14692

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GENERAL INFORMATION

The doctor-patient relationship is both highly personal and at the same time, a contractual agreement. This will provide a clear framework for your relationship with your provider as well as necessary business policies of Phatak & Labuzetta Physicians, PLLC. Feel free to discuss any of this with your provider.

At all times you retain the option to withhold or withdraw consent.  Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.

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THE PROCESS

The services provided by Phatak & Labuzetta Physicians, PLLC are intended to be educational and to help facilitate open communications between patients and their primary care physician.  Phatak & Labuzetta Physicians, PLLC is not and should never be considered a replacement for your primary care physician. At all times, your primary care physician should remain your primary point of contact, especially in case of an emergency.

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The Phatak & Labuzetta Physicians, PLLC providers will do their best to understand you and your health, as well as to help you clarify what it is that you want for yourself.  If you have questions about our recommendations, they should be discussed whenever they arise. If your doubts persist, we would be happy to recommend another professional for an additional opinion.

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ABOUT YOUR PROVIDERS

• Dr. Ajinkya Phatak (New York License # 295560)(Missouri License # 2012017792)(Kansas License # 04-35788)(Iowa License # MD-44188)

• Dr. Michael Labuzetta (New York License # 294835)

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Additional information about your provider can be found at www.doctalk.health. Please reach out if you have any questions regarding this information.

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If you have any concerns with regards to my services you may file a complaint, at:

• New York State Office of The Professions: http://www.op.nysed.gov/opd/complain.htm

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FEES & PAYMENT

DocTalk has a very simple pricing model.

We charge a fixed fee of

$59 for a 15 minute appointment,

$99 for a 30 minute appointment and

$149 for a 45 minute appointment.

You can schedule your appointment depending on the complexity of your questions.

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APPOINTMENTS / CANCELLATION POLICY

Appointments with DocTalk are available in three durations: 15 minutes for $59, 30 minutes for $99, and 45 minutes for $149. All appointments are conducted via the Setmore video conferencing platform. Since appointments are reserved specifically for you, a minimum of 24 hours’ notice is required for cancellations. If you do not cancel within this timeframe, you will be charged the full appointment fee. However, extenuating circumstances will always be considered. If your appointment is canceled by the provider, you will have the option to reschedule at no additional cost or receive a full refund. No other refunds will be issued. Choose the appointment length that best suits the complexity of your questions.

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If requested, clients will be provided with a receipt with appropriate diagnoses and codes which may be submitted to their insurance company for reimbursement. Please contact your insurance provider to ask about the limits of their coverage for services from an out-of-net network provider if you choose to use insurance. If your insurance, HMO, third party pay, or other managed care provider does not reimburse for all or any portion of Phatak & Labuzetta Physicians, PLLC services, you will be solely responsible for the fee for the appointment. Payment is due and payable upon receipt of a bill from our office.

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If you request a copy of your records, you may be charged a reasonable fee for the costs incurred in fulfilling such request, in accordance with applicable federal and state law.

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CONFIDENTIALITY

The session content and all relevant materials to the client's treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons.

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With regards to confidentiality of your protected health information, you have certain rights as set forth in the Notice of Privacy Practices, as amended. The current version of the Notice of Privacy Practices is available at www.doctalk.health.

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In accordance with the Notice of Privacy Practices, there are also certain situations where your PHI may be used or disclosed your PHI without an authorization from you. By signing this document, you are also acknowledging that you have received, understood, and signed the Notice of Privacy Practices.

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Occasionally, our providers may need to consult with other professionals in their areas of expertise to provide the best educational services to you. Information about you may be shared in this context without using your name. Phatak & Labuzetta Physicians, PLLC is not responsible for any use of your confidential information after it has been lawfully disclosed to a third party.

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(ELECTRONIC COMMUNICATION/PHONE/SOCIAL MEDIA POLICIES)

The best way to reach your provider outside of a regularly scheduled appointment is by email, which is only answered by Phatak & Labuzetta Physicians, PLLC staff. Phatak & Labuzetta Physicians, PLLC will make every effort to return your email within Forty-eight (48) hours, except for weekends and holidays.

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Phatak & Labuzetta Physicians, PLLC does not conduct sessions via unscheduled phone calls, e-mail messages, through the client portal, or text. Since you can't see facial expressions or hear the providers tone of voice, and vice versa, responses will be kept brief. E­mail should only be used for questions concerning appointments or resources, and not for medical questions given the limited confidentiality.

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TELEHEALTH POLICY          

Telehealth refers to providing services remotely using telecommunications technologies. One of the benefits of telehealth is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time.

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There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to care, better continuity of care, and reduction of lost work time and travel costs. Effective telemedicine is often facilitated when the provider gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Providers may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences.

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When using information technology in healthcare services, potential risks include, but are not limited to:

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The Provider’s inability to make visual and olfactory observations. The provider’s inability to make visual and olfactory observations of clinically relevant issues such as: your physical condition including deformities, apparent height and weight, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, and any physical or medical conditions including bruises or injuries. Potential consequences thus include the provider not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the provider.

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Risks to confidentiality. There is potential for other people to overhear sessions if you are not in a private place during the appointment. Phatak & Labuzetta Physicians, PLLC will take reasonable steps to ensure your privacy. It is important for you to find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your device.  You should participate in sessions only while in a room or area where other people are not present and cannot overhear the conversation. Phatak & Labuzetta Physicians, PLLC has a legal and ethical responsibility to make best efforts to protect all communications that are a part of medical treatment. However, the nature of electronic communications technologies is such that the providers cannot guarantee that patient communications will be kept confidential or that other people may not gain access to our communications. Phatak & Labuzetta Physicians, PLLC will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of communications (for example, only using secure networks for medicine sessions and having passwords to protect the device you use -for telemedicine).

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In the course of our telemedicine meetings:

• You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

• All existing confidentiality protections are equally applicable.

• Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.​

• Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

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Please let your provider know if you have any questions about exceptions to confidentiality.

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Your provider will maintain a written record of your session in accordance with Phatak & Labuzetta Physicians, PLLC policies. You may have to have certain computer systems to use telemedicine services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software.

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Appointments are most effective when clinical discussions occur at your regularly scheduled sessions. If a non-urgent issue arises, you should feel free to attempt to reach your provider to schedule an appointment at the general email. Your provider will try to respond within Forty-Eight (48) hours except on weekends and holidays.

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Phatak & Labuzetta Physicians, PLLC will not engage in telemedicine with clients who are currently in an emergency situation requiring high levels of support and intervention. If you need immediate assistance, contact your family physician or the nearest emergency room. Before engaging in telemedicine, your provider will work with you to develop an emergency response plan to address potential crisis situations.

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EMERGENCIES

Phatak & Labuzetta Physicians, PLLC is unable to offer emergency care or intervention. In the event of an emergency, it is important to *FIRST* be in touch with agencies that can respond to an immediate need. In emergencies, call 911, or visit the nearest emergency room.

If you disclose to your provider that you are experiencing an emergency, your provider is obligated to make necessary arrangements to ensure your safety, such as referring you to hospitalization. Phatak & Labuzetta Physicians, PLLC requires an Emergency Contact Person (ECP) who may be contacted on your behalf in a life-threatening emergency only. Please provide this person's name and contact information when booking your appointment. You will see a section to enter your ECP information.

Either you or your provider will verify that your ECP is willing and able to go to your location in the event of an emergency. By you entering this hame and phone number indicates that you understand that your provider will only contact this individual in the extreme circumstances stated above.

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COURT APPEARANCES

If a patient requests a Phatak & Labuzetta Physicians, PLLC provider to testify in court, or to provide any statements or materials to be used during legal proceedings, an additional fee to such request shall be implemented by a mutual agreement of the parties based on the scope of the request and the time required for the preparation of the materials or appearance for a testimony.

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EXPECTED BEHAVIOR & TERMINATION

Phatak & Labuzetta Physicians, PLLC reserves the right to terminate work with clients that threaten their provider physically, verbally, or legally; or if continued care is deemed to be no longer beneficial. By signing this document, you are agreeing to maintain professional conduct with your provider and Phatak & Labuzetta Physicians, PLLC staff in and out of the office.

Phatak & Labuzetta Physicians, PLLC and the providers may terminate treatment after appropriate discussion with you and compliance with the termination process provided under the state law.

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BY CLICKING ON THE BUTTON ABOVE I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. I ALSO UNDERSTAND THAT AT ALL TIMES I RETAIN THE OPTION TO WITHHOLD OR WITHDRAW CONSENT WITHOUT AFFECTING THE RIGHT TO FUTURE CARE OR TREATMENT OR RISKING THE LOSS OR WITHDRAWAL OF ANY PROGRAM BENEFITS TO WHICH I WOULD OTHERWISE BE ENTITLED.