I authorize the release of medical information necessary to process this claim or provide prudent medical care either by mail, phone or fax. I also request payment of benefits to be made to the party who accepts assignment.

WE HAVE A 24 HOUR NOTICE CANCELLATION POLICY.

PRESCRIPTION REFILL POLICY: All patients requiring refills of their medications must notify their pharmacy, who will request a refill from our office. Refill requests require 48 hours notice and are handled at the end of our patient day, so please plan ahead. I have read and understand the above policies.

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is an addendum to our existing Financial Policy, we require you to read and sign it prior to treatment.

All patients must complete our information and insurance forms before seeing the doctor.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AND AMERICAN EXPRESS. WE OFFER EXTENDED PAYMENT PLANS (please consult with our Patient Accounts Representatives).

INSURANCE ASSIGNMENTS

In most cases we will accept assignment of insurance benefits. However, we do require a form of payment to cover amounts not paid by insurance. (Forms of payments include authorizations to pay by credit card, check or cash.) If your insurance company has not paid your account in full within 90 days of date of service we will automatically transfer your balance to your extended plan.

Payment in full is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information and original claim form (when required). Your insurance policy is a contract between you and your insurance company. We are not a party to that contract.

Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable and necessary under Medicare and/or other medical insurance.

INSURANCE PLANS WHERE WE ARE A "PARTICIPATING PROVIDER"

All co-pays and deductibles are due on the date services are rendered, with the exceptions of Medicare, in which case we will bill once we receive the explanation of benefits from Medicare.

USUAL AND CUSTOMARY RATES

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

MISSED APPOINTMENTS

Unless canceled 24 hours in advance. we reserve the right to charge for missed appointments at the rate of a normal office visit. Please help us serve you better by keeping your appointments.

Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns.

I have read this Financial Policy and understand and agree with its terms.

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do. we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment. payment. or healthcare operations.

By signing this form. you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing. signed by you. However, such revocation will not be retroactive.

 

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment. or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon the execution of this consent.

 

You can either submit the form to us electronically or print the form and bring it with you. All submissions adhere to HIPAA privacy standards of data encryption.