RESPONSIBILITY PARTY STATEMENT: AS THE RESPONSIBLE PARTY, I AGREE THAT ALL CHARGES THAT ARE NOT DIRECTLY PAID BY MY INSURANCE WILL BE MY RESPONSIBILITY.

1. WE WILL COLLECT YOUR OFFICE SPECIALIST CO PAY + CO INSURANCE IF APPLIES AT EACH VISIT. YOUR COPAYMENT/ CONSULTATION FEE CAN TAKE UP TO THREE WEEKS TO CLEAR FROM YOUR BANK.

2. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN PRE-SURGERY DIET WHICH CONSISTS OF LIQUIDS FOR ONE WEEK PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR SURGERY WILL CANCELED BY DR. JAYASEELAN.

3. YOU WILL BE REQUIRED TO PAY YOUR FEES DEDUCTIBLE, CO-INSURANCE ONE WEEK PRIOR TO SURGERY. THIS AMOUNT VARIES FROM PERSON TO PERSON, DEPENDING ON THE INDIVIDUAL CO-PAYMENT, CO-INSURANCE, DEDUCTIBLE AND HEALTH PLAN. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR SURGERY WITHIN 48 HOURS PERIOD.

4. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. THE ONLY EXCEPTION IS GIVING INFORMATION TO YOUR INSURANCE COMPANIES AND DISABILITY COMPANIES. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

5. PLEASE BE RESPONSIBLE ABOUT THE INSURANCE INFORMATION YOU PROVIDE TO OUR OFFICE. IF YOUR INSURANCE COMPANY, POLICY, AND OR JOB CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY OUR OFFICE. IF YOUR BENEFITS HAVE CHANGED AND YOU DID NOT NOTIFY OUR OFFICE IN WRITING, YOU WILL INCUR ALL MEDICAL COSTS. THIS INCLUDES SURGEON’S FEES, ANESTHESIA FEES, FACILITY FEES, ATTORNEY’S FEES AND ANY COSTS INCLUDED IN RECOVERING THE AMOUNTS DUE TO ALL THAT HAVE PROVIDED CARE FOR YOU.

* THIS IS ONLY AN ESTIMATE UNTIL YOU ARE SEEN IN A CONSULTATION WITH THE SURGEON. AS EACH INDIVIDUAL IS DIFFERENT AND LONGER TIME FOR SURGERY MAY BE REQUIRED.

I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS.

1. Once you have been seen by the Physician or Nurse Practioner a pre-determination will be started. This process takes between 4-6 weeks. Please contact your insurance company if it is within this time frame. Pre Determination with the insurance companies that require additional information will not be sent until all information requested is received. The insurance company cannot make a pre-determination until they have all the needed information.

2. We will collect your office specialist co pay + co insurance if applies at each visit. Your copayment/consultation fee can take up to three weeks to clear from your bank.

3. If you are denied from your insurance company, you may appeal. Our office does not handle that appeal for you. You may utilize www.obesitylaw.com for appeals. We will furnish you with a copy of your charts/file to assist you.

4. Unless told otherwise by the doctor, you are required, to follow a certain pre-surgery diet which consists of
liquids for one week prior to surgery. If you do not adhere to the liquid diet your surgery will canceled by Dr. Jayaseelan.

5. You will be required to pay your fees deductible, co-insurance one week prior to surgery. This amount varies from person to person, depending on the individual co-payment, co-insurance, deductible and health plan. A cancellation fee will be charged to you if you fail to cancel your surgery within 48 hours period.

6. The adjustments needed for your follow up range from $0-$250 depending on your insurance coverage, surgeon, with the exception of self-pay patients. Self-pay patients receive 3 evaluations/adjustments, (fills/unfills), then they are $175 thereafter. New patients that were not banded by Dr. Jayaseelan and are uninsured will be charged $250 for evaluation and or any adjustment necessary you will not be seen unless you supply us with your surgery information and any fills done elsewhere to include OP REPORT AND ADJUSTMENT LOG.

7. You and your health information are protected by HIPPA regulations. We will not give anyone information about you, unless we have written an authority to do so. The only exception is giving information to your insurance companies and disability companies. If you need more information on HIPPA laws please ask receptionist.

8. Please be responsible about the insurance information you provide to our office. If your insurance company, policy, and or job changes, it is your responsibility to notify our office. If your benefits have changed and you did not notify our office in writing, you will incur all medical costs. This includes surgeon’s fees, anesthesia fees, facility fees, attorney’s fees and any costs included in recovering the amounts due to all that have provided care for you.

9. If you are self-pay for the Gastric Sleeve, regular follow up visits in our office are included for the first year following surgery. This does not include any testing that may be required post-operativly.

* This is only an estimate until you are seen in a consultation with the surgeon. As each individual is dif ferent and longer time for surgery may be required.

I (we) certify that this form, along with all other forms have been fully explained to me, that I (we) have read
them or have had them read to me and understand their contents.

Prescriptions:
Prescription refills may be obtained by contacting your local pharmacy. They will phone or fax us with the information about your prescription.

We send all prescriptions electronically to your local pharmacies as well as to your mail order provider.

 If you have not been seen in 3 months  you will need to make an appointment for an office visit to obtain the prescription. Without an office visit the a presciption will not be sent.

No prescriptions  for controlled substances will be approved if it has been 3 months since your last office visit, and these prescriptions will not be filled on Fridays or weekends.

All controlled substance prescriptions requires an office visit every 1-3 months.

Electronic refill requests may take up to 72 hours to be complete. 

If you have a problem getting your prescription, please call our office during normal business hours.

In general, all patients are required to be current patients seen within the last 6 months to get a phone or auto refill. However, some patients may require labs or an office visit more frequently.

Lab Policy
If you require labs work prior to getting your prescription refill, then you must make a future office appointment at the same that the lab order is written. This is to ensure that the lab results are available for Dr. Jayaseelan to review with you when the refill prescription is written.

Test Results
In order to ensure the confidentiality of your protected health information and to give you the time and attention you need from your healthcare provider, you will be asked to schedule a follow-up appointment to discuss your test results (including lab work). If your test results need to be discussed before your scheduled follow-up appointment, our office will contact you immediately.

Prescription Refill Policy

To maintain an efficient office, provide quality medical care, and avoid any possible prescription abuses. The following policy explains the General Prescription Guidelines and Prescription Refill Policy for Dallas Bariatric Center

The office of Dr. Jayaseelan does not deviate from the Prescription Refill and Controlled Substances Policy. Failure to comply with this policy may result in dismissal from our practice.

If, at any point, you have questions about anything, please feel free to give us a call.

General Guidelines
Please remember to discuss any medication concerns and all refill requests you have with your physician at your regularly scheduled appointments.
All chronic medications will require regular follow-up visits at our office. Your physician will determine the appropriate interval between visits.
Please ensure that you have enough medication to last until your next scheduled visit.
If you need refills and have an appointment, please request them at the time of your visit.
If you have any questions regarding medications please discuss these during your appointment.
If you have a formulary or a preferred medication, you MUST let our office know prior to the physician writing a prescription or calling in your medication. For example, if you want a brand name or need a less expensive medication, let our office know.
It is your responsibility to notify the office in a timely manner when refills are needed.
Approval of your refill may take up to three (3) business days so please be courteous and do not wait to call. If you use a mail order pharmacy, please contact us fourteen (14) days before your medication is due to run out.
Preferred drugs and tiered formularies fluctuate depending on your health insurance. If you don’t have a system that alerts you of formulary restrictions as you prescribe, you will likely receive calls from pharmacies requesting new prescriptions for alternative medications.
It is important to keep your scheduled appointment to ensure that you receive timely refills. Repeated no shows or cancellations will result in a denial of refills.
If for any reason you feel your medication needs to be adjusted or changed please contact us immediately.
If you think that you are having an allergic reaction to a medication, call the office immediately or go to the nearest emergency room.
All new patients must be established with the office of Dr. Jayaseelan prior to having a prescription refilled.
Medications are prescribed for your use only. They are not meant to be shared with others.
Samples are only available for branded medications and if we have them in stock; there is no guarantee that we will have the drug you may need. We do not stock pain medications!
Additional lab tests may be required to determine exact dosages of prescribed medications; your insurance may or may not cover these tests. Check with your insurance company if you have any specific questions regarding your coverage.
Your provider will not diagnose or treat over the phone.
New or unresolved problems will require a clinic appointment.

Refill Medications
All regular medications, non-controlled/non-narcotic prescriptions, require a follow up appointment with your provider every 3-6 months (more frequent if necessary). This will be considered a regular office visit.
All prescription refill requests should originate from the patient by contacting their pharmacist asking to request the refill electronically.
If your prescription bottle indicates you have refills left, you do not need to contact our office. Contact your pharmacy and they will refill it for you; be sure to give the pharmacy adequate time to fulfill your request, Please plan at least five (5) days in advance of your medication running out.
Refills can only be authorized on medication prescribed by providers from our office. We will not refill medications prescribed by other providers.
Refills will not be granted if a patient has persistent or worsening symptoms.
Medication refills will only be addressed during regular office hours (Monday-Friday 8am-3pm).No prescriptions will be refilled on Saturday, Sunday or Holidays.
The urgent care staff will not return any phone calls regarding refills.
The on-call physician will not answer calls regarding medication refills.
Please notify your provider on the next business day if you find yourself out of medication after hours.
All chronic non-controlled medications will only be granted a maximum of 5 refills unless instructed otherwise by the healthcare provider.
Patients should have been seen in the last 6 months before a refill is given.
If you have not been seen within this time your refill may be denied
It is your responsibility to make your followup appointment to ensure you do not run out of your prescription. Please do not call the office and expect your urgent request for a refill without an office visit. 

Controlled Substances Policy

 A prescribing agreement with strict parameters will be signed in the rare event that long-term use of these medications is required.

It is our strict policy that there will be no refills of controlled substances called-in over the phone or by an after-hours physician when the office is closed.
NO EXCEPTIONS.
Controlled-substances/narcotic prescriptions require a follow up appointment every 30-90 days.
When it is medically necessary for our doctors to treat you with a controlled substance, we abide by all local, state and federal regulations.
You will be asked to sign a controlled substance contract (see link below) when your medical condition(s) warrant ongoing treatment with controlled substances. Compliance with your controlled substance contract is not optional, and violation of this policy may result in termination of medication therapy and/or your removal as a patient from Dr. Jayaseelan's Practice.

Patients are responsible for their controlled substance medication.
Controlled substances (pain, sleep, muscle relaxants, stimulants, anti-depressants) are tracked by the Drug Monitoring Program (PMP). Pharmacies and physicians DO track your usage of controlled substances through obtaining an online report, which annotates physicians who have prescribed, and pharmacies that have dispensed these medications.

Prior Authorizations
Many medications require prior authorization. Depending on your insurance this process may involve several steps by both your pharmacy and your provider. Once the prior-authorization form is completed, both the pharmacy and Dr King’s office must wait for approval.
Neither the pharmacy nor the provider can guaranty that your insurance company will approve the medication. You may be required to make an office appointment to complete the process.

 

 

I HEREBY ACKNOWLEDGE THAT I HAVE BEEN PRESENTED WITH A COPY OF NIRMAL S. JAYASEELAN, M.D. NOTICE OF PRIVACY PRACTICES.

IN ORDER TO PROTECT YOUR PRIVACY, WE ASK THAT YOU COMPLETE THE FOLLOWING SECTION, WHICH WILL ENABLE US TO BETTER SERVE YOU IN THE FUTURE. PLEASE WRITE YOUR INITIALS BESIDE EACH STATEMENT. WE ALSO ASK THAT YOU ENTER THE NAME OF EACH PERSON YOU WOULD LIKE TO HAVE ACCESS TO YOUR ACCOUNT (THIS INCLUDES YOUR SPOUSE). ALSO, PLEASE SIGN AND DATE THE BOTTOM OF THIS FORM. YOU MAY UPDATE THIS INFORMATION AT ANY TIME. THANK YOU FOR YOUR COOPERATION.

1. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN DIET WHICH CONSISTS OF LIQUIDS NIGHT PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR PROCEDURE WILL BE CANCELED BY DR. JAYASEELAN.

2. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

3. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR PROCEDURE WITHIN 48 HOURS PERIOD.

I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS