In an effort to provide you with the highest quality healthcare and still maintain lower prices for our services, we have established this financial policy to assist you in understanding and complying with our clinical practice's service fees.

 

The patient or patient's guardian is responsible for payment of all services rendered by our physicians/providers.

 

If you have medical insurance, Pinellas Internal Medicine Associates will be happy to accurately and efficiently submit all claims to your insurance company. Many of the services provided in this office are covered by insurance companies. However, in cases where a service has not been paid for by your insurance within 60 days, you will be personally responsible for the bill. Your balance payment is due within 30 days upon receipt of your bill.

 

It is your responsibility to verify all insurance policies regarding co-pays, deductibles and coverage. All patient co-pays are due at the time of visit. If you do not have your co-pay, your appointment will be rescheduled, as it is our responsibility to comply with your insurance policies.

 

If you have high deductibles, have no insurance or require services not covered by your insurance, Pinellas Internal Medicine Associates will be happy to provide you with the opportunity to meet with our financial/billing advisors. A financial estimate, possible discounts and agreement form can be set up that allows you to make monthly payments for all of the services rendered.

 

Payment plans available to our patients include: cash, checks (for existing patients), MasterCard, Discover and Visa (credit/debit). A fee of $25.00 will be assessed on all returned checks.

 

An outstanding balance of 120 days, with no contact from you will be referred to our collection agency and you will be dismissed from the care of our practice. Should you file bankruptcy, you will also be dismissed.

 

We are more than happy to meet and work with you on a payment plan, but these arrangements must be made in advance with our financial billing advisors. If you have questions, please feel free to contact our Office Manager at (727) 544-8300.

Formulary Benefits Data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan.

By signing below I give permission for Pinellas Internal Medicine Associates to access my pharmacy benefits date electronically through RxHub. This consent will enable Pinellas Internal Medicine Associates to:

Determine the pharmacy benefits and drug copays for the patient’s health plan.

Check whether a prescribed medication is covered (in formulary) under a patient’s plan.

Display therapeutic alternatives with preference rank (if available) within drug class for non- formulary medications.

Determine if a patient’s health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies.

Download a historic list of all medications prescribed for a patient by any provider.

 

In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub.

GENERAL INFORMATION

In order to provide our patients with the best quality of care in the most timely manner, we have established these policies.  We welcome your comments, positive and negative, and any suggestions you may have.  Our clinic office hours are 8:00 a.m. to 5 p.m. Monday through Thursday, and 9:00 a.m. until noon on Fridays.  Doctors’ schedules may vary from these hours.  Physicians are on call 24 hours a day, seven days a week for emergencies. 

OUR POLICIES

Payment- Payment in cash, check, or credit card is expected at the time of service unless other arrangements are made in advance.  We accept all major credit cards.

 Co-Payments- All insurance and HMO co-payments are due at the time of the office visit prior to seeing the doctor.  We are unable to bill for co-payments.

 Office Visits- Office visits are made by appointment, only.  We are not a walk in clinic.  The office is extremely busy and we try hard to accommodate everyone.  When possible, please call at least one to two weeks before you would like to see the doctor as we cannot guarantee same-day or next-day appointments.  Please call and let us know if you will be unable to make your scheduled visit.  The nature of our practice is to give our patients the best possible care and service.  Therefore, you may experience delays in being seen.  Please be assured that you will be attended to as promptly as possible and be given the same careful attention as those who came before you. 

 

Failure to Keep Appointments- After three times of failing to notify us that you will be unable to keep your appointment, you will be required to select a different clinic for your medical needs.  There will be a charge of $35 for appointments broken with less than 24 hours notice.  There will be a $75 charge for any new patient appointments broken with less than 24 hours notice that request to make another appointment.

 

Medical Students and Residents- From time to time, the doctors may have medical residents or students who are in training with them.  If you do not wish to be seen by a student or a resident, please let us know in advance. 

 

Phone Calls- The doctor is quite busy during office hours, therefore he or she cannot be interrupted during clinic unless it is an emergency .  If you need to speak to the doctor or the nurse, please leave your detailed message and phone number with the receptionist and someone will return your call by the end of the work day.  If you need to speak to the doctor after hours for emergencies, he or she will be paged and return your call.  

 

Prescriptions- If you need a refill, please contact your pharmacy and allow 3 business days for your request to be completed.  The doctors do not call in prescriptions after business hours. If you haven’t seen the doctor recently, you may need to make an appointment to review your medical history and make any necessary changes before your prescription can be refilled.  Some prescriptions require prior authorization from your insurance company and this may take up to a week, so please call well in advance of your needs.  Always provide the name of the medication, dosage, and the pharmacy used when calling the office. This office does not prescribe chronic narcotics. 

 

Referrals- We try to obtain referrals as soon as possible, however some may take up to seven business days.  We will send the referral as soon as it is obtained.  We appreciate your patience during this time.  We cannot get a referral for a doctor that is not included in your insurance. 

 

Living wills and Powers of Attorney- Please inform the receptionist if you have living wills or powers of attorney that pertain to your care.  We will need copy to put into your chart.

 

 Medical Records- Your medical records may only be released after you have filled out and signed the appropriate forms’.  A copying charge of up to $1.00 per page or a flat fee of $25.00 will be billed to you. 

 

Appointment confirmations will be left via answering machine, voice mail, text message, or portal message.

 

I have read the above office policies, I understand them, and I agree to them as a condition for being seen by my doctor. 

The Health Insurance Portability and Accountability Act of 1996 (HIPPA), established a “Privacy Rule” to help insure that personal health care information is protected for privacy.  The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment or health care operations.  

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy.  We strive to always take reasonable precautions to protect your privacy.  When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need of your health care information regarding treatment, payment or health care operations, in order to provide health care that is in your best interest.  

We fully support your access to your personal medical records.  We may have indirect treatment relationships with you (such as laboratories that only interact with the physician and not the patients), and may have to disclose personal health information for purposes of treatment, payment or health care operations.  

You may refuse to consent to the use or disclosure of your personal health information, but this must be done in writing.  Under this law, we have the right to refuse to treat you should you refuse all or part of your Personal Health Information.  You may not revoke actions that have already been taken which relied on this or previously signed consent.  

If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer.  You have received our Privacy Notice (Confidentiality of Patient Medical Records) and have the right to review it, to request restrictions, and to revoke consent in writing. 

Screening:  For this section, please complete what applies to you 

If you have any medical records, labs, blood pressure readings, glucose readings, medication lists, or any other information, you can upload that document by clicking on the"Browse Files" button below and uploading your file to us.

 

If you do not have any documents to upload to us, click on the "SUBMIT" button and you have completed our New Patient Paperwork Packet.