Policies

For any additional questions please contact our office at (603) 386-0100

Family Health Matters of Salem Office Policies

At Family Health Matters of Salem, we are committed to providing you with quality care. To ensure transparency and understanding, please review and acknowledge the following policies:

Insurance Coverage: Patients or their legal guardians are responsible for all health insurance deductibles, co-insurance, co-payments, and any non-covered services. Co-payments are due at the time of service.

Primary Care Provider Assignment: If your insurance plan requires you to designate a primary care provider (PCP), it is your responsibility to select a provider affiliated with Family Health Matters of Salem. Failure to do so may result in full financial responsibility for services rendered.

Insurance Accuracy: Providing knowingly incorrect or terminated insurance information will result in the patient being held responsible for the full balance of services rendered.

Non-Payable Services: If your insurance plan determines that a service is not payable, you agree to be responsible for the full cost of that service. All charges must be paid within thirty (30) days of receiving the initial billing statement.

Uninsured Patients: If you are uninsured, you agree to pay for all medical services at the time of service. A deposit is required at time of booking and a valid credit card must be on file for any remaining balances.

Appointment Deposits and Payment Methods: A valid credit card is required to schedule and hold appointments. Your card may be kept on file securely to guarantee future services.

Referrals: Please allow at least ten (10) business days for our office to process and complete referral requests. No retroactive referrals will be issued.

It is your responsibility to confirm whether a referral is required by your insurance plan before your appointment. If a referral is required and not obtained in advance, your insurance may deny the claim, and you will be responsible for the full cost of the visit.

We strongly advise that you contact your insurance carrier immediately if you have not followed the proper referral procedure. Additionally, it is your responsibility to confirm that any specialist, facility, or service recommended by our office is in-network with your insurance and will be covered. If you choose to go outside your network, your claim may be denied, and you will be financially responsible for all charges incurred.

Please also familiarize yourself with your insurance plan’s policies regarding urgent care and emergency room visits, as some plans require referrals for non-emergent care, even in urgent care settings.

Credit Card on File: Family Health Matters of Salem requires all patients to maintain a valid credit or debit card on file. This card will only be charged under specific and limited circumstances, as outlined in this agreement. Please review the following policy carefully. The patient or legal guardian/authorized representative, authorize Family Health Matters of Salem to securely store my credit, debit card, HSA healthcare card information in a HIPAA-compliant platform within the electronic medical record system (eClinicalWorks).

Patient/Guardian understands it is their responsibility to provide valid credit/debit/hsa card information and to update it as necessary. All updates or changes to card information must be submitted in writing.

Missed Appointments and Courtesy Rescheduling

When you schedule an appointment, we set aside enough time to provide you with the highest quality of care.  Should you need to cancel or reschedule an appointment please contact our office as soon as possible and no later than 24 (business) hours prior to your scheduled appointment.  This gives us time to schedule other patients who may be waiting for an appointment. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment.  If you find yourself in this position, please call to discuss the situation with our office.

At Family Health Matters of Salem, we are committed to respecting your time and extending the same courtesy in return. If we need to reschedule your appointment, we will notify you as soon as possible. While we strive to give at least 24 hours' notice, unforeseen circumstances such as inclement weather, provider illness, or urgent medical events may occasionally prevent this. We sincerely hope to avoid any inconvenience and appreciate your patience and understanding should such situations arise.

Patients who miss scheduled appointments without providing at least 24 business hours' notice may be subject to discharge from the practice.

Patient/Guardian authorizes Family Health Matters of Salem to charge the card on file for fees related to missed appointments ("no-shows") and appointments canceled with insufficient notice ("late cancellations").

Patient/Guardian understands the following fee schedule, effective as of July 1, 2022:

No-Show – Standard Visit (including telehealth): $75.00

No-Show – Annual Physical Exam: $150.00

Late Cancellation – Standard Visit (including telehealth): $75.00

Late Cancellation – Annual Physical Exam: $150.00

Patient/Guardian acknowledges that these fees are not covered by insurance and will not be billed to my insurance Provider nor may an HSA or health benefit card be used to pay these fees. Patient/Guardian is personally responsible for these charges.

Co- Payments: Patient/Guardian understands that all insurance-required co-payments are due at the time of service. If I fail to make this payment prior to or during my appointment, the credit, health benefit card, or debit card on file will be charged for the co-payment amount, in accordance with my insurance policy. Whenever possible the card will be charged the same day as the appointment. In some instance the copay will be charged when the insurance company notifies Family Health Matters of Salem of the balance due for the missed copay.

Deductibles and Balances

Patient/Guardian understands that billing statements will be available through the patient portal, the Healow app, or may be requested for secure email or text delivery.

Patient/Guardian acknowledges that any unpaid balance will be automatically charged to the card on file 30 days after a billing statement is issued. Family Health Matters of Salem will make every reasonable effort to notify me via email prior to this charge. If I pay the balance before the 30-day period, no automatic charge will occur.

Please note: All outstanding account balances must be paid in full before scheduling any appointments. Failure to pay outstanding balances may result in delays or denial of prescription refills, referrals, and the ability to schedule future appointments.

Delinquent Accounts: Unpaid balances may incur late fees and may be referred to a collection agency or attorney for recovery. Non-payment may also result in dismissal from the practice.

Returned Payments: Any returned payments will be subject to an administrative fee in addition to any bank charges incurred by our office.

Failure to comply with these policies may result in late fees (starting at $20.00) and/or dismissal from the practice, at the discretion of Family Health Matters of Salem.

By signing, Patient/Guardian acknowledges that they have read, understand, and agree to the terms of this Credit Card Financial Responsibility Agreement. Patient/Guardian consents to the use of the credit/debit/hsa card on file as outlined above.

Treatment of Minors; Family Health Matters of Salem is committed to providing respectful, safe, and developmentally appropriate care for all patients, including minors. Please review the following policy regarding the treatment of individuals under the age of 18:

Minors may be seen in the office for scheduled appointments; however, no invasive treatments—including immunizations—will be administered unless the minor is accompanied by a parent or legal guardian. This is at the discretion of the healthcare provider.

A parent or guardian may designate another adult (age 18 or older) to accompany the minor to appointments. In this case, written authorization must be submitted in advance, and must include:

The full name and relationship of the accompanying adult

Signed permission from the parent or legal guardian

The accompanying adults must present with matching photo ID

In the event that a minor wishes to discuss sensitive or confidential topics, Family Health Matters of Salem follows established protocols to protect the privacy, safety, and rights of the minor in accordance with applicable laws and professional standards. These protocols may include private time with the provider, confidentiality of certain health disclosures, and appropriate involvement of guardians when necessary to ensure the minor's well-being.

Annual Physical Appointment: Patient/Guardian understands that the annual physical exam—including a Comprehensive Physical Exam (CPE), Well Child Check, or Medicare Wellness Visit—is intended to review social, family, and medical history, as well as ongoing health issues. This visit also includes screenings required by my insurance, such as mental health, safety, tobacco and alcohol use assessments, which are conducted through questionnaires.

As part of the visit, my provider will:

Review all current medications, supplements, and respiratory devices.

Update my allergy list, including any non-medication allergies.

Confirm any other providers involved in my care and review any changes they may have made.

Ensure all preventive screenings (e.g., mammograms, colonoscopies, vaccines) are up to date.

Perform a complete physical “hands on” examination.

If the Patient is sick, experiencing an urgent issue, or a new abnormality is discovered during my exam, the provider may choose to treat that issue and reschedule the physical for another time. Patient/Guardian understands that insurance companies do not cover both a physical exam and a sick visit, follow up, or focused exam during the same appointment. If new or acute concerns are addressed during this visit, Patient/Guardian may be responsible for a co-pay or deductible as required by my insurance. To ensure thorough care, a separate appointment may be scheduled for those additional concerns.

Women’s Health: Patient needing routine gynecological care will be referred to an OB/GYN or women’s health specialist. We will continue to provide care for women’s health-related sick visits.

Controlled Medications: In accordance with strict state regulations, the prescribing of controlled substances must follow specific medical guidelines to ensure patient safety and regulatory compliance. This policy applies to the use of controlled medications for conditions including, but not limited to:

Pain Management

Mental Health Disorders

ADHD

Initial Assessment: Mandatory for all patients and includes:

Standardized screening tools (e.g., SOAAP) and formal evaluation when required.

A complete historical evaluation to include past medical, family and social history

Review of refill history via the NH Prescription Monitoring Program (PMP)

Assessment of risks and contraindications

Trial of various treatment modalities as applicable

Randomized drug screenings, diagnostic testing

Specialist referrals when appropriate

Risks of Controlled Medications

Physical Dependence: Abrupt discontinuation may cause withdrawal symptoms (e.g., cramping, anxiety, sweating).

Tolerance: Medications may become less effective over time.

Addiction: Risk is higher in those with a history of substance use but can occur in anyone.

Overdose: Can be fatal, especially when mixed with alcohol or other substances.

Pregnancy Risks: Can cause dependence in newborns and potential developmental issues. Inform your provider if you plan to become pregnant.

Ongoing Care and Monitoring

Annual Physical Exam: Required for all patients on controlled medications.

Comprehensive Follow-Up Visit(s): These appointments are essential for evaluating the effectiveness of medications, monitoring side effects, ensuring the use of the lowest effective dose, and discussing alternative treatment options or plans for tapering when appropriate. Individualized care plans will be established to determine the appropriate follow-up schedule for each patient. For example, medical weight loss patients may require monthly visits, while those prescribed anxiety medications may be seen every three months. The frequency of follow-up is ultimately at the provider’s discretion.

Please note: newly prescribed medications may require more frequent follow-up appointments.

Continuation of Medication and Legal Compliance:
Our practice fully cooperates with law enforcement and regulatory agencies in cases of controlled substance misuse. Treatment will continue only if medications are beneficial and the patient complies with this agreement. Failure to do so may result in discontinuation, with tapering as necessary. If complications such as addiction arise, the patient will be referred for specialized treatment. In the event that misuse. Sale, or diversion is suspected; all prescriptions will be voided, no future controlled medications will be prescribed, patient may be terminated from the practice and local law enforcement and DEA mat be notified. Note: lost and stolen prescriptions will not be replaced without a valid police report and is left to the discretion of the provider.

The Patient/Guardian agrees to the following terms:

I will only use medications as prescribed for the indicated condition.

I will keep medications secure and never share, trade, or sell them.

I will not use illegal drugs or abuse alcohol.

I will only obtain controlled medications from Family Health Matters of Salem.

I will notify the practice within 24 hours if another provider prescribes a controlled medication.

I will use only one pharmacy and inform the office of any changes within 24 hours.

I will comply with random urine drug screenings.

I will bring my medications to the office when requested.

I will participate in all recommended treatments and keep scheduled appointments.

I give permission for the practice to communicate with other providers, pharmacists, and relevant individuals to ensure appropriate use.

I will follow provider instructions for tapering and discontinuation.

I understand lost prescriptions or medications will not be replaced.

I consent to eligibility checks through the ECW system for all prescriptions as well as state programs.

Weight Loss Medications: Patients may receive verbal and written information about the risks and benefits. By starting medication, the patient acknowledges understanding potential side effects such as nausea, vomiting, headache, diarrhea, and rare but serious risks including medullary thyroid cancer and pancreatitis. Patients are required to adhere to monthly check in appointments either in person or via telehealth.

HIPAA Compliance 2025

Patient Consent for Use and Disclosure of Protected Health Information (PHI)

1. Consent for Treatment, Payment, and Healthcare Operations (TPO)

By signing this consent, I authorize Family Health Matters of Salem to use and disclose my protected health information (PHI) for the purposes of treatment, payment, and healthcare operations (TPO), as described in the practice’s Notice of Privacy Practices.

2. Notice of Privacy Practices

I understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. Family Health Matters of Salem may update this notice at any time. To obtain a revised copy, I may submit a written request to:

Family Health Matters of Salem
32 Stiles Road, Suite 103
Salem, NH 03079-2853

3. Communication Consent

With my consent:

Telephone: Family Health Matters of Salem may contact me by phone at my home or alternative numbers provided. They may leave voicemail messages or speak in person regarding appointment reminders, insurance matters, clinical information (e.g., lab results), or telehealth communications (audio and video).

Text Messaging: The practice may send text messages to any phone numbers I have provided for purposes related to my care or appointments.

Mail: The practice may send mail, including appointment reminders and patient statements, to my home or an alternative address.

Email: The practice may send appointment reminders and patient-related information to my provided email address. I understand that while reasonable safeguards are taken, email is not a guaranteed secure method of communication. Additionally, records will only be sent via email when requested and written consent has been provided in writing.

4. Requests for Restrictions

I have the right to request restrictions on how my PHI is used or disclosed for TPO. Family Health Matters of Salem is not obligated to agree to such restrictions. However, if the practice does agree, it will be bound by those terms unless the restriction is revoked or legally voided.

5. Right to Revoke Consent

I may revoke this consent in writing at any time, except where actions have already been taken based on prior consent. I understand that if I do not sign this consent—or if I revoke it—Family Health Matters of Salem may decline to provide treatment.

Copyright Notice
© 2002 Gates, Moore & Company. Used with permission. Content adapted from:
Bush J. The HIPAA Privacy Rule: Three Key Forms. Family Practice Management. February 2003:29–33.
Available at: www.aafp.org/fpm/20030200/29theh.html

Consent to Use of Artificial Intelligence (AI) and Digital Communication Platforms: As part of our ongoing efforts to enhance the quality, efficiency, and coordination of your care, Family Health Matters of Salem may utilize artificial intelligence (AI) technology and digital communication platforms in the management and delivery of healthcare services.

Use of AI and Digital Tools:
Family Health Matters of Salem may use AI-powered technologies for clinical support, communication, scheduling, documentation, and coordination of care. These tools are used in conjunction with, and under the oversight of, licensed healthcare professionals.

Technology Platforms Involved:
The following platforms—among others—may be used in your care:

FREED Communications – for secure digital communication, including appointment reminders and care coordination.

Klara Communications – for messaging between you and your care team, appointment scheduling, and secure information exchange.

PRISMA by eClinicalWorks – for unified health records and data exchange.

CommonWell Health Alliance – for secure sharing of health records across different healthcare providers and systems.

Patient Privacy and Data Security:
All platforms utilized are HIPAA-compliant and designed to protect the confidentiality, integrity, and security of your personal health information (PHI). AI tools are used in accordance with applicable federal and state laws and under provider supervision to ensure appropriate use of your data.

No Replacement of Clinical Judgment:
AI is used to support—not replace—the clinical judgment of your provider. All decisions regarding your care are ultimately made by licensed healthcare professionals.

Right to Opt-Out:
You may request not to receive communications through certain platforms (such as text or email) by informing our office in writing. However, this may affect the efficiency of communication and care coordination.

Authorization to Access External Providers and Facilities: Patient/Guardian authorizes Family Health Matters of Salem to obtain and integrate medical information from external healthcare providers and facilities into my electronic health record within the eClinicalWorks system. This information may include, but is not limited to, medical histories, test results, imaging, and treatment summaries, and is used to support continuity and quality of care

Code of Conduct Policy: Family Health Matters of Salem, we are committed to fostering a safe, respectful, and professional environment for our patients, staff, visitors, and healthcare providers. To maintain a standard of dignity and mutual respect, we have established the following Code of Conduct:

Unacceptable Behavior The following behaviors will not be tolerated under any circumstances:

Disrespectful, abusive, or threatening language or conduct

Racist, discriminatory, or harassing behavior of any kind

Verbal or physical intimidation

Disruption of clinic operations or interference with the care of others

Consequences for Violations: Any patient who violates this Code of Conduct may be discharged from the practice and will be notified in writing.

Family Members or Visitors: Individuals accompanying a patient who engage in inappropriate behavior may be asked to leave the premises immediately. Continued or severe violations may result in restrictions on future visits or removal from the facility.

Our Expectations:

Treat one another with courtesy, respect, and professionalism

Communicate openly but appropriately

Work collaboratively to support a safe, inclusive, and caring healthcare environment

Vaccine Policy: Family Health Matters of Salem, we prioritize the health and safety of all our patients, staff, and community. After careful consideration and consultation with our medical team, we have established the following vaccine policy for pediatric patients:

Delayed Vaccination Schedule

We understand that some families may request a modified or delayed vaccination schedule. In such cases:

Any deviations must be approved by a provider.

All required vaccinations must be completed within the first year of life.

Optional Vaccine Exceptions

While we encourage adherence to the CDC-recommended vaccination schedule, we respect individual choices regarding certain vaccines. Therefore, patients may choose to decline the following vaccines without risk of dismissal:

Rotavirus

Varicella (Chickenpox)

HPV (Gardasil)

COVID-19

Non-Adherence to Policy

Families who choose not to follow the required vaccination policy (outside of the optional

exceptions listed above) will be:

Provided with medical care for a 30-day transition period

Asked to seek alternative primary care after that period to better align with their healthcare preferences

Vaccine and Titer Policy for Adult Patients
To ensure appropriate immunization status is established and maintained for new patients aged 18 and older who are unable to provide documented evidence of childhood vaccinations.

All new patients 18 years of age and older who are unable to provide a verifiable copy of their childhood immunization records will be required to undergo laboratory serum testing (titers) to assess immunity to major vaccine-preventable childhood illnesses. These illnesses include, but are not limited to:

Measles, Mumps, and Rubella (MMR)

Varicella (Chickenpox)

Hepatitis B

Tetanus, Diphtheria, and Pertussis

Polio (as clinically indicated)

Procedure:

During the initial intake process, patients without immunization documentation will be informed of the requirement to complete lab-based titer testing.

Orders for appropriate titers will be placed, and patients will be directed to a partnered lab facility for testing.

Upon receipt of lab results:

If titers indicate adequate immunity, no further action will be required.

If results show the patient is under-immunized or non-immune, a personalized care plan will be developed by the provider. This plan may include recommended vaccinations, follow-up testing, or other steps as clinically appropriate.

Individualized Care Planning:
The care plan will take in to account the patient's medical history, risk factors, current health status, and personal preferences. It will aim to ensure both patient safety and adherence to current CDC and ACIP immunization guidelines.

Exceptions:
Any patient who refuses titer testing or vaccinations will be counseled on potential health risks. Refusal will be documented in the medical record, and providers will continue to offer routine care while revisiting immunization discussions as appropriate.

Review:
This policy will be reviewed annually and updated as needed to align with current public health recommendations.

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