Exemplar Allergy - Office Patient Policies
{name}, welcome to our office. We are please that you have chosen Exemplar and our allergy specialists for your medical care. In order for to provide the quality care that you expect in an efficient manner, we must insist that you read and comply with the following policies:
1. We require reasonable notification (24 hours when possible) of cancellation or rescheduling of all appointments. If three (3) appointments are missed without notification, we will, unfortunately have to terminate our patient relationship.
2. All insurance cards (including Medicaid) need to be available at the time of each appointment. If there is no insurance card available at the time of your appointment, you will be asked to reschedule for another day and time.
3. If you arrive over 15 minutes late for your appointment, the appointment will have to be rescheduled.
4. If you (the patient) are 17 years old or younger, you must be accompanied by a parent or legal guardian. A Consent Form signed by a parent or legal guardian is required if the under-18 year old patient is accompanied by another adult. This is a legal requirement and no exceptions will be made. (Consent Form Required)
5. If you do not have insurance and are paying with a check or debit/credit card, you need to pay a minimum of half (50%) of the total charges at the time of each visit. The remainder will be due in 30 days.
6. Exemplar offices operate on a cash-less basis. We accept VISA, MASTERCARD, AMEX and DISCOVER (credit or debit card) with proper identification. CASH will only be accepted by the Office Manager or if other arrangements have been made.
7. Authorizations (from your insurance company), if necessary, are also your responsibility and are required on the date of service. Please contact your primary care physician or insurance company with any questions. All co-pays, co-insurance and deductibles are due in full at your appointment. For questions concerning billing, you may call our billing office at: AMBS - 304-363-7000.
8. By signing below, you authorize any holder of medical or other information about you to release to the Social Security Administration and Healthcare Administration or its intermediaries or carriers, or to the billing agent of the physician, any information needed for this or related claim. You permit a copy of this authorization to be used in a place of the original; and request payment of medical insurance benefits either to myself or the part who accepts assignments.