top of page



This notice describes how health information about you may be used and disclosed and how you can get access to this information.


Please review this Notice carefully as it is a part of Your Electronic Medical Record.


1. We have a legal duty to protect health information about you.


We are required by law to protect the privacy and confidentiality of health information about you, which we call "protected health information," or "PHI" for short. We are required to explain how we may use PHI about you and when we can give out PHI to others. You have rights regarding PHI about you as described in this Notice. We are required to follow the procedures in this Notice. We have the right to change our privacy practices and to make new Notice provisions effective for all PHI that we maintain by posting the revised notice at our location, making copies of the revised notice available upon request, and posting the revised notice on our website.


2. How we use or disclose protected health information.


We must use and disclose your health information to provide information:  To you or someone who has the legal right to act for you (your personal representative); and To the Arizona Department of Health and Human Services, if necessary, to make sure your privacy is protected. Where required by law:  We have the right to use and disclose health information to pay for your health care and operate our business, and for your treatment by your healthcare providers. For example, we may use your health information:  To provide health care treatment to you. We may use and disclose PHI about you to provide, coordinate, or manage your health care and related services, for example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when consulting or referring you to another healthcare provider.  To obtain payment for services: We may use and give your medical information to others to bill and collect payment for the treatment and services provided to you.  For health care operations: We may use and disclose PHI in performing business activities that allow us to improve the quality of care we provide and reduce health care costs, examples may include, reviewing and improving the quality, efficiency, and cost of care that we provide to you and our other patients; reviewing and evaluating the skills, qualifications, and performance of healthcare providers taking care of you; and/or providing training programs for students, trainees, healthcare providers or non-health care professionals to help them practice or improve their skills.


We may use or disclose PHI without your permission in the following limited circumstances:  When required by law, for example, when a disclosure is required by federal, state, or local law or other judicial or administrative proceeding; When necessary for public health activities, for example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; For reporting of victims of abuse, neglect or domestic violence, for example, we may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect, domestic violence; For health oversight activities, for example, we may disclose PHI about you to a state or federal health oversight agency which is authorized by law to oversee our operations; For judicial and administrative proceedings, for example, we may disclose PHI about you in response to an order of a court or administrative tribunal; For law enforcement purposes, for example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries; When the use and/or disclosure relates to a deceased former patient, for example, we may disclose PHI about the deceased patient to a coroner, medical examiner, or a funeral director as necessary to carry out their duties and as authorized by law; We may disclose PHI to organ procurement organizations and/or similar entities; For research, for example, we may use or disclose PHI for research purposes only with approval of an reputable Institutional Review Board which must follow a special approval process; to specialized government functions, for example, if you are a member of the armed forces of the United States or a foreign country, we may disclose PHI to appropriate military authority as is deemed necessary for lawful intelligence or national security activities; For workers’ compensation, for example, we may use or disclose PHI as permitted by the laws governing the workers’ compensation program or similar programs that provide benefits for work-related injuries or illnesses; To manage or coordinate your health care, for example, this may include telling others about your treatments, services, products and/or other health care provided by our providers.


3. More stringent law:


Highly Confidential Information:  Federal and applicable state laws may require special privacy protections for highly confidential information about you. "Highly confidential information" may include confidential information under Federal and State law governing genetic information, psychiatric/mental health, alcohol, and/or drug abuse information as well as state laws that often protect information such as that dealing with HIV/AIDS.


4. You have the right to object to certain uses and disclosures of PHI and, unless you object, we may use or disclose PHI in the following circumstances:


We may share with a family member, relative, friend, or other person previously identified by you, PHI directly related to that person's involvement in your care or payment for your care. We may share with a family member, personal representative, or other person responsible for your care PHI necessary to notify such individuals of your location, general condition, or death.


You have the right to inspect or get a copy of your medical records that we authored and/or produced about you that we maintain which does not include any medical records from other healthcare providers and/or vendors.  Your request for medical records must follow our policies and procedures.  Your written request should describe the information you want to review and should be forwarded to  We may refuse to allow you to inspect or obtain copies of this information in certain limited cases.  We may charge you a fee of up to $0.75 per page for copies or the rate established by the Department of Health.  We may also deny a request for access to health information under certain circumstances if there is a potential for harm to yourself or others.


You have the right to request changes to your medical records, that we authorized and/or produced, about you if you state a reason why this information is incorrect or incomplete.  Your healthcare provider might not agree to make the changes you request.  If we do not agree with the requested changes, we will notify you in writing within ten (10) business days and we will have your objection included in our records.


5. Any other use or disclosure of PHI about you requires your written authorization:


Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing.  If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.


6. Our Promise to You Regarding High Quality Care:


If applicable, our board-certified Nurse Practitioners, Physician Assistants, Naturopathic Doctors, and/or Registered Nurses will listen carefully to you, take the time to conduct a thorough exam, and explain everything clearly. You will understand why you are not feeling well and know what to do before we depart from one another.


We may assist you in arranging for further treatment with specialists, if it is warranted.


Communication (including sharing your records) with other providers and your insurance company(ies) may need to occur.  You hereby grant permission to Healthy Wings, LLC, its staff, contractors, and healthcare providers to share needed information related to our visits as needed.


Our relationship is highly depended upon mutual trust and respect.  We will not knowingly or inadvertently audio or visually record your visit and/or interactions with our Healthcare Providers and/or staff without your expressed and/or written consent.  Likewise, you agree not to secretly, knowingly, or inadvertently, using audio or visual recording devices record interactions with our Healthcare Providers and/or staff without their expressed and written consent.  Anyone admitting to or caught audio or video recording transactions while doing business with our Healthcare Providers and/or staff at any time will be dismissed from the care of Healthy Wings LLC, Healthy Wings Family & Psychiatric Healthcare, and/or its staff, contractors, assigns, and/or representatives as well as will face civil and/or criminal charges to the fullest extent of the law.


7. Our Customer Service-Orientated Payment Structure:


We accept most insurance plans.  Depending on your insurance, your specific co-payment, co-insurance, or deductible (“cost-sharing fees”) must be collected during your visit as per your insurance plan policy.  Payment in full is expected at the time of service which may include your co-payment and/or your portion of your unmet yearly deductible or co-insurance amounts, any outstanding balances, as well as any service fees that may not be covered by your insurance provider.  If you do not have insurance, our services are more affordably priced than traditional physician office, urgent care, and emergency room visits.  Certain plans may not cover all of our services or may have specific referral requirements. Any cost sharing fees for your specific plan must be collected prior to the commencement of your visit.  Please have a hard copy of your valid insurance card, proof of Identification, and a valid form of payment at the time of service.  We accept most major credit cards, checks, and cash. We require a credit or debit card to reserve and confirm all appointments.  Without these necessary documents, your visit may be rescheduled, and a cancellation fee will be assessed that will be due and payable at the time of cancellation. 


We promise all credit or debit card(s) entrusted to us will be maintained in a confidential manner with our merchant service vendor(s).  You hereby give us permission and consent to make charges to your credit or debit card(s) for amounts disclosed for any appointment fees, including co-payments, co-insurances, deductibles, outstanding balances, and/or for any missed appointments that were not cancelled before the applicable cancelation timeframe (24 hours before the scheduled appointment date and time).


Appointments cancelled and/or rescheduled within 24 hours of your appointment, for any reason, will result in a $75.00 cancellation fee.


There may be an outstanding amount due after our bill is processed by your insurance company. Based on your insurance plan and medical benefit(s), you could be responsible for charges beyond your co-payment, co-insurance, or deductible paid at the time of the visit for things like your unpaid deductible, co-insurance, or services not included in your benefit(s).


Instead of sending you a bill, we will automatically charge your balance to the credit card provided at the time of service. You will be asked to authorize these payments at the time of your initial visit.


If allowed, a delinquent account may be charged interest at 10% if not paid within ten (10) days of the initial invoice date; an additional late fee at 10% will be assessed on any remaining balance every 30 days thereafter for invoices that remains unpaid.

8. Out-of-Pocket Charges:


If you have not met your deductible, you have co-insurance responsibilities, you do not have insurance, or you do not have a plan we currently accept, we accept most major credit cards, personal pre-printed checks, and cash. If your insurance plan offers out-of-network benefits, we will give you a receipt that you can submit to your insurer for reimbursement. We will gladly inform you of the anticipated cost of your visit before we provide services. 


Charges may be higher based on the length and complexity of your visit.  Your visit may be more complex if you need care for more than one health condition or have an advanced condition.  The Healthcare Provider will attempt to keep you informed of any additional charges, if needed.  There will be no upcharges or unnecessary fees - THAT'S OUR GUARANTEE!

9.  Discount Cards and/or Programs:


There are various discount cards that Healthy Wings, LLC may offer that are not affiliated with Healthy Wings, LLC.  If any discounts are offered, they are offered merely as a courtesy to our patients. 


10.  Timelines and Guarantees:


We guarantee all services will be provided as articulated to you by the Healthcare provider.  You understand that any dates and/or timelines discussed may be dependent upon other healthcare providers, technicians, or service providers; accordingly, we make no expressed or implied guaranteed delivery or completion date and/or time. 


11.  The aforementioned Notice of Privacy Practices and Patient-Provider Policies are subject to change.  Healthy Wings, LLC, its assigns and/or representatives are committed to providing you notice of changes in our Policies that may affect how we provide health care to you and your family.                                                                                         

  Revised: 12/11/2022 3:26 PM




Thank you for choosing Healthy Wings Family & Psychiatric Healthcare (HWLLC) as your Primary Care Provider. We are committed to providing you with personal, quality, and affordable health care. This document spells out the important elements of our Payment Policies that may be found in our Notice of Privacy Practices & Patient-Provider Policies. Please read it, ask any questions that you may have, and sign in the space provided. A copy will be provided to you upon request.

  1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured with a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but do not have an up-to-date insurance card, payment in full is required for each visit until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Please be advised, that according to the Patient Privacy and Affordable Care Act and most insurance contracts, the Annual Physical Exam that is typically provided FREE, once every 12 months, by your insurance company is reserved for patients that are WELL and are not experiencing any sickness and/or acute concerns.

  2. Co-Payments and Deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and/or deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment or deductible at every visit.

  3. Non-Covered Services and/or Outstanding Balances. Please be aware that some – and perhaps all – of the services you receive may require you to pay a portion of the services, may not be covered, and/or may not be considered reasonable or necessary by Medicare or your Insurance company. You must pay for these services in full at the time of the visit or immediately after Medicare or your insurance company advises us of your cost sharing amounts; (note, your insurance company automatically mails this information to you, as well). In addition, instead of sending you a bill, you hereby authorize HWLLC to automatically charge your balance to the credit card provided at the time of service.

  4. Proof of Insurance. All patients must complete our Patient Registration forms before seeing the healthcare provider(s). We must obtain a copy of your valid driver’s license or state photo ID and the current, valid insurance information to obtain proof of insurance.  If you fail to provide us with the correct insurance information, you may be responsible for the full balance of the claim.

  5. Claim Submission. We will submit your claims and assist you in any way we can to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request within five (5) days of the request. Please be aware that the balance of your claim is your responsibility, whether your insurance company pays your claim or not. Your insurance benefits are a contract between you and your insurance company.

  6. Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim, the balance will automatically be billed to you.

  7. Nonpayment. If your account is 60 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated with our Billing Department. Please be aware that if a balance remains unpaid, we may refer your account to a collections agency, and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you will have 30 days to find alternative medical care. During that 30-day period, our healthcare provider(s) may be able to treat you on what we consider an emergency basis only.

  8. Missed appointments. Our policy is to charge for missed appointments not canceled within 24 hours of the scheduled appointment. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment or by telephoning our office directly if you need to cancel a scheduled appointment.


Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges of the area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. 

Revised 04/06/2022 @ 5:52 p.m.

Schedule an Appointment TODAY!

bottom of page