Privacy Policy

Your Information.

Your Rights.

Our Responsibilities.


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.


Click on the file below to open up our Privacy Policy. Feel free to print it out.

HIPAA Privacy Notice.pdf
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Office Policies and Procedures

OFFICE HOURS: Our office is open Monday through Thursday from 7:30 AM to 4 :00 PM. We can be reached at (740)577-9181. We start answering the phone at 7 AM Monday through Thursday. Patients are not scheduled from 12:00 PM through 1 PM for lunch. However, our phones remain open for messages and appointment scheduling. We are closed in observance of major holidays.


APPOINTMENTS: We see patients by appointment only. Only patients who are fully vaccinated against COVID-19 are allowed in the office. Same day appointments are usually available for urgent or sudden illness. Please arrive at least 10 minutes prior to your appointment time so that we may update your billing and contact information. Proof of insurance is required at every appointment.


NEW PATIENTS: First time patients are asked to arrive at least fifteen minutes early for their first appointment. We ask that you bring your photo ID, insurance cards, and a current medication list. It is the policy of this practice that all new patients submit their medical records for review to the doctors prior to making an appointment, in order to ensure that we are the right fit for you. To ensure quality care, Jackson Family Practice does not treat patients we have not seen (i.e., we will not call in prescriptions or offer medical advice for patients prior to their initial visit).


If you are a “No Show” to your first appointment, you will be Dismissed from the practice.


WELLNESS VISITS, YEARLY PHYSICALS, OR “WELCOME TO MEDICARE” PREVENTATIVE VISITS: You must inform the receptionist at the time you make your appointment if this is the reason for your appointment. We have to schedule the appropriate amount of time for these visits. We cannot change your appointment to one of these classifications after the fact.



  • The best time to get a prescription refill is at your appointment.
  • If you need to call for refills, don’t wait until you have run out. Call (740)577-9181 option 2, follow the prompts, and give us two business days to fill your request. Check with your pharmacy at that time.
  • Some medications have potential side effects that must be monitored. We require check-ups every 3 – 4 months for these medications. Be sure to keep these follow-up appointments.
  • Some prescriptions cannot be called in. The prescription must be printed for you to pick up. When you arrive to pick up a printed prescription, please have your photo ID with you.
  • Do not call after hours for prescription refills.
  • Refills of prescription medications that fall under the general category of controlled substances such as narcotics and certain mood-altering agents will require an appointment at least once every 90 days. Patients receiving these medications MUST bring their controlled substances (in the original bottle) with them to ALL appointments.


SAMPLES: We sometimes offer you samples to help you try out a new medication before you purchase it. Remember that samples are not a long term way to fill your prescription. We do not always have samples of your medications. Please do not rely on samples for medications you take long term.


AFTER HOURS AND EMERGENCIES: For a serious emergency, call 911 right away! If you are not sure, call the office. You will receive the cell phone number of your physician. Use this number to seek the advice of your physician about your emergent medical issue. Do not call the physician’s cell phone to request an appointment or a refill, or to ask when you next appointment will be – those are calls best left to our normal business hours. As a rule, we do not call in antibiotics or narcotics.


FMLA AND DISABILITIES FORMS: In general, we do not complete or perform Long-Term Disability Forms and Evaluations. We do require that FMLA Forms and Short-Term Disability Forms be completed in person during our regular office hours, at which time our providers may refer you to appropriate specialists for further evaluation and management. There is a $25.00 administrative charge for forms that are requested outside of an appointment. Payment is due at the time you pick up these

forms. Please allow 7-10 business days for the completion of these forms. If you would like the forms mailed to your insurance company, payment is due prior to mailing. FMLA forms require that you come in for an appointment.


TREATMENT OF MINORS: Patients under the age of 18 must be accompanied by a responsible adult or have written permission for treatment from a parent or guardian.


AUTO ACCIDENT: If your injury is a result of an auto accident, you are required to pay for services and then collect from the auto carrier. We will not file your insurance but will provide you with a receipt to do so.


LIABILITY INJURY: If your injury is a result from another party’s negligence, you are required to pay for services and then collect from the responsible party. We will not file your insurance but will provide you with a receipt to do so.


WORKER’S COMPENSATION: If your injury is due to an accident in your work place, please inform the receptionist immediately. We are not authorized to treat you for this type of claim. You will need to contact your supervisor for instructions on how to file a worker’s compensation claim. We regret any inconvenience this may cause.



A “no show” is someone who misses an appointment without canceling it within one (1) business day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in your medical chart as a “no show”.  An administrative fee of $50.00 will be billed to your account. You will be sent a letter alerting you to the fact that you failed to show for a scheduled appointment and did not cancel the appointment within one (1) business day in advance along with the bill for the administrative fee. A copy of the letter will be placed in your medical record. Three (3) “no-shows” will result in your being dismissed from the practice (See DISMISSAL section below).


**Please note that No-Show charges are the patient’s responsibility and will not be billed to your

insurance company.


In the event that you have a special circumstance regarding your missed appointment, please contact our office manager. We understand that there may be issues beyond your control and want to be understanding of special circumstances.


DISMISSAL: If you are “Dismissed” from the practice, it means you can no longer schedule appointments, get medication refills or consider us to be your doctor. You have to find a doctor in another practice.

Common reasons for Dismissal are:         

  • failure to keep appointments, frequent no-shows (see NO SHOW POLICY above);
  • noncompliance, which means you won’t follow physician instructions about an important health issue (which includes deciding not to get vaccinated against COVID-19),
  • abusive to staff,
  • failing a part of your Pain Contract, if you are under one.

We will send you a letter to your last known address notifying you that you are being dismissed from the practice. If you have a medical emergency within 30 days of the date on this letter, we will see you. After that, you must find another doctor. We will forward a copy of your medical record to your new doctor after you let us know who it is and sign a release form.


If you are Dismissed from the practice, you will not be able to be seen by any of the physicians of the practice.


CHANGES IN ADDRESS, BILLING, OR CONTACT INFORMATION: Please notify our office in writing of any changes of address, telephone, billing or contact information. It is imperative that we have the most current information on file.


INSURANCE POLICIES & FORMS: Our office will submit claims for insurance carriers with which we participate. We strongly encourage you to contact your insurance carrier ahead of time and verify appropriate coverage.


We also require proof of current insurance at check-in for every visit. It is essential that you provide all the necessary information about your insurance, both primary and secondary. Since changes in insurance coverage are frequent, it is our policy to obtain a copy of your card(s) for applicable insurance. Please be prepared to present your card(s) at each visit. In case of a new policy, a copy of the enrollment form specifying insurance company name and phone number, employer and his/her phone number, insured employee name, and date of birth will be required.


FEES & PAYMENTS: Payment in full is due at the time services are rendered unless we are submitting charges to your insurance company. Copays and deductibles are due at time of service or your appointment may be rescheduled. Self-pay patients are required to make a $50 down-payment towards the charges incurred upon check-in. We accept VISA and MASTERCARD. We also accept money orders, cashier checks, cash, and personal checks. Those patients without proof of coverage may be required to pay in full or be asked to reschedule their appointments. If we are not contracted with your particular insurance plan, you must pay in full at time of service. You will be given a copy of our charge slip to submit to your insurance company for reimbursement purposes.


A $25 service fee will be charged for returned checks due to insufficient funds. We may also elect to discharge you from our practice should you fail to comply with our policy. Should you require a payment plan, our office manager will be glad to discuss the options with you. There is a $50 late fee for accounts that are outstanding by more than 6 months.


NURSE OR MEDICAL ASSISTANT: We often refer to the staff that assist our doctor as “nurses”. They definitely do help you and the doctor and you probably think of them as nurses. But they are not technically “nurses” because they are not licensed by the state as an LPN and RN. They are “Medical Assistants”. This means they have technical school or on-the-job training in providing medical assistance to the physicians. They take blood pressure, weigh you, ask about your symptoms, give injections, schedule tests, and answer your questions. They also help you learn how to live with your diabetes and heart disease. They work under the direct supervision of the physicians.


COMMUNICATIONS: I authorize my healthcare provider and/or any entity authorized by my healthcare provider, including those using automated dialing systems, automated messages, email, text messaging and/or other electronic communication to contact me for any reason by using any telephone number, email address and/or mailing address associated with my account.


PRIVACY POLICY: This notice describes how medical information about you may be used and disclosed and how you can get access to this information. When it comes to your health information, you have certain rights.


You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.


You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.


You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.


If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.


You can complain if you feel we have violated your rights by contacting us at P.O. Box 190, Jackson OH 45640. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting We will not retaliate against you for filing a complaint.


For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In the following situations, you have both the right and choice to tell us to: share information with your family, close friends, or others involved in your care; share information in a disaster relief situation; include your information in a hospital directory. We will require a signed release form that is signed in front of one of our staff members. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.


In the following cases, we never share your information unless you give us written permission: marketing purposes, sale of your information, and most sharing of psychotherapy notes.


We typically use or share your health information in the following ways. We can use your health information and share it with other professionals who are treating you. We can use and share your health information to run our practice, improve your care, and contact you when necessary. We can use and share your health information to bill and get payment from health plans or other entities. We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see:


We can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone’s health or safety. We can use or share your information for health research. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. We can use or share health information about you: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; for special government functions such as military, national security, and presidential protective services. We can share health information about you in response to a court or administrative order, or in response to a subpoena.


We are required by law to maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.


For  more  information  see:


Changes to the Terms of This Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.


UPDATED 07/15/2022












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