Adler Family Practice
2026 Practice Policies, Consents, and Other Information
Please review and sign below

Telemedicine Access 2025

Missed or late telemedicine appointments impact the daily schedules of all our patients, in-clinic and telemedicine. Please help us provide for your care when requesting a telemedicine appointment.
Telemedicine appointments are the same as in-clinic appointments - your provider can be late. We reserve the right to require in-clinic appointments if you leave the telemedicine queue because your provider is late. Please do not schedule your telemedicine appointment without allowing enough time.
It is the patient's responsibility to ensure that their computer/phone and internet systems are sufficient to perform telemedicine (audio AND video) appointmentsbefore your appointment. If a telemedicine appointment is missed or late due to a technical problem, we reserve the right to cancel the appointment (if late), or require in-clinic appointments going forward.
You may only have 3 telemedicine appointments in a row. We will need to see you in clinic every 4th appointment.
If you miss your telemedicine appointment for any reason, it can only be rescheduled based on clinic schedule availability, it cannot be rescheduled based on the urgency of the reason for the missed appointment. Our regular $50 missed appointment charge may apply.

Payment and Billing Policy

Insurance.
We participate in most insurance plans. If you are not insured payment is due in prior to services being rendered. If you are insured, but don’t have current proof of insurance (a current insurance card), payment is also due in full prior to services being rendered. Knowing your insurance benefit coverage is your responsibility, for our provided services, and those we order for you. Please contact your insurance company directly with questions regarding your coverage, we’re unable to answer coverage questions due to frequent changes and numerous variations in insurance coverage and plans.

Co-payments and deductibles.
All co-payments, deductibles, and any balance due must be paid prior to services being rendered, there are no exceptions.

Non-covered services.
Please be aware that some or all of the services, orders, tests, treatments or referrals you receive from us may not be covered or may not be considered reasonable or necessary by your insurance plan. You are personally responsible for the costs incurred by these services by us or outside entities.

Proof of insurance.
We are required to keep a copy of a your valid identification and valid proof of insurance on file at all times. If you fail to provide us with correct and updated insurance or personal contact information, you may be responsible for costs incurred as a result of incorrect or outdated information.

Claims submission.
We will submit your claims and assist you as possible to help get our claims paid through your insurance. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Coverage or information changes.
If your insurance or personal information changes, please let us know as soon as possible so we can update your information to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.  It is your responsibility to update your name, address, phone, employment, insurance, or other relevant information changes as they occur.

Nonpayment.
If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency.  This may result in discharge from our practice.

Missed appointments.
There is a $50 charge for all appointments that are missed without a cancellation received by us on the previous business day.  If two appointments are missed within 12 months, you may be discharged from our practice.  New patients who miss any of their first 3 appointments with us may be subject to discharge from our practice.  Medicaid and Centennial insurance patients: Your signature below is your consent to assume this charge.  

Unpaid Balances. 
Balances less than $200 must be paid before additional services will be rendered by our clinic.  Balances of $200-$500 may be paid off over 2 months when a payment plan is arranged in advance with our administrative staff.  All other AFP payment policies apply.

Document Fees.
There is a minimum $40 document fee for all documents requiring medical signatures (FMLA, leave, etc).  This excludes simple return to work notes.

Returned Checks.
There is a $45 charge for all returned checks.

Payment Responsibility.
I understand that the insured party is financially responsible for any balance not covered by insurance, including co-pay, out of network charges, and tests, orders and referrals excluded by my policy for any reason. I also understand the insured will be responsible for all charges incurred should there be no coverage on the date of service. I hereby authorize release of medical information necessary to file a claim with my insurance.

Other Practice Consents and Policies

“Good Fit” Policy:
We strive to provide excellent care to all of our patients, however, as a small independent business, we reserve the right to discharge patients from our practice that are inappropriate, hostile, or abusive with our staff, providers, or the towards the clinic operations in general, including Internet and Social Media postings. This includes if a provider believes that there is a "Poor Therapeutic Relationship" with a patient.

An appointment is required for:
- New (to your provider) or changing prescriptions,
- To address a new or changing condition, illness or symptom,
- To provide a requested referral and all medical order,
- Documents require medical signature or review,
- To review completed orders or test results.

Receiving Test Results:
Test results including CTs, Xrays, Blood Tests and others, fall into two categories: Medically Concerning or Not Medically Concerning. Test results may be slightly abnormal, yet still be Medically Unconcerning as related to your care or health. Test results are provided to you via your Patient Portal. Your Portal notifies you with an email when results or other information is made available to you If you have test results that are Medically Concerning, we will contact you to schedule an appointment to review these with you, if one isn't already scheduled.

Provider Communications and Access:
Our AFP Patient Portal provided to you provides staff and provider messaging, appointment requests, and bill payment functions, as well as others.  Otherwise, access to our providers outside of a scheduled appointment is very limited.

Receiving Your Test Results:
Test results including CTs, Xrays, Blood Tests and others, fall into two categories: Medically Concerning or Not Medically Concerning.  Test results may be slightly abnormal, yet still be Medically Unconcerning as related to your care or health.  Test results are provided to you via your Patient Portal. Your Portal notifies you with an email when results or other information is made available to you  If you have test results that are Medically Concerning, we will contact you to schedule an appointment to review these with you, if one isn't already scheduled.

Medication Refills:
Please contact your pharmacy first to request a refill.  You can also request refills using your Patient Portal 

Home-Bound Patients:
We are unable to provide, or continue to provide, care for patients that become permanently home-bound for any reason.  Once a patient becomes home-bound, we will assist with securing placement with an appropriate group or provider.

Treatment Non-Compliance:
If a patient fails to follow a treatment plan, as agreed upon with their AFP provider, that increases the health risk of the patient due to willful treatment non-compliance, we reserve the right to discharge them from our practice if we feel that this is causing significant risk to their health.

Controlled Substance Prescribing: 
We no longer provide controlled substance prescriptions for opioids, benzodiazepine (Ativan, Xanax, etc), or hypnotic (Ambien, Lunesta, etc) medications that require daily use.  Some of these drugs may be provided for acute issues on a short-term basis.  If you are a new patient requiring these medications for use every day, a referral to an outside prescriber (A Pain Specialist, Psychiatry, etc.) can be provided.

Cannabis Cards:
We provide cannabis cards for qualifying conditions (see the NM DOH Cannabis Application for a list of these conditions).  For patients currently diagnosed with an active cancer, a Cannabis Application can be sponsored by our clinic. Otherwise, there is a charge for these applications.  Documentation of your condition is required, and for psychiatric complaints, a letter from a NM Licensed Psychiatric provider confirming the diagnosis may be required.

Consent to Treat:
I consent to evaluation, diagnostic procedures, testing, and treatment as directed by my Adler Family Practice Provider or his/her designee. I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care. I understand that this Consent to Treat will be valid for each visit I make to Adler Family Practice until revoked by me in writing.

Consent to Release Information:
I acknowledge that Adler Family Practice may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Adlers Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Adler Family Practice. I acknowledge and consent to allow Adler Family Practice to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may “opt out” and not have my protected health information disclosed through health information exchange systems by providing the signed Adler “opt-out” form to the practice location where I receive treatment.

Consent to Use Artificial Intelligence (AI) Technology
I understand that this clinic may use artificial intelligence (AI) tools to assist licensed healthcare providers in documentation, clinical decision support, and treatment planning during medical and psychiatric visits. These tools are used to improve accuracy, efficiency, and quality of care but do not replace professional judgment or the provider–patient relationship. I consent to the use of AI technology during my visit and acknowledge that my personal health information will be protected in compliance with all applicable privacy and confidentiality laws, including HIPAA.

Consent to Photograph/Digital Imaging:

I consent to photographs/digital images for treatment, and to verify identity for payment purposes. I understand that the Adler Family Practice will retain the ownership rights to these photographs/digital images, but that I will be allowed access to view them or obtain copies