ESTABLISHED PATIENT UPDATE
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Can we text you on this number
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YES
NO
Alternative Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pharmacy
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Insurance Company (If self pay, put self pay) UPLOAD COPY
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Insurance ID (If Self Pay, just put xxx)
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FRONT OF CARD optional
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BACK OF CARD optional
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PAYMENT POLICY PLEASE READ EACH ONE VERY CAREFULLY
You must Initial each section
INSURANCE We participate in most insurance plans, including Medicare. If you are not insured by a plan, we do business with, payment in full is expected at each visit. If you are insured by a plan, we do business with, but do not have up to date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage
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COPAYMENTS, COINSURANCE AND DEDUCTIBLES All co payments, deductibles and coinsurances must be paid at the time of service. The Only exception, will be if a card is left on file (see additional consent form) This arrangement is part of your contract with your insurance company. We may make exceptions on a case by case basis. Should we make an exception and you are billed for your co pay or deductible there will be a $5.00 billing fee. In addition, any balance over 30 days will be assessed a $5.00 service charge,I acknowledgeignature
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*******CARD ON FILE AGREEMENT ******* OUR SYSTEM SECURELY STORES YOUR CREDIT CARD. ONCE CARD IS SCANNED, IT IS LOCATED IN THE CREDIT CARD COMPANY FILE, NOT OUR SYSTEM. NO ONE CAN ACCESS THE CARD.We can securely maintain your credit card information on file with our merchant services. This information will be securely held until your insurance provider has paid their portion of your bill or if payment has not been received from the insurance provider in 60 days.At that time, any balances, which you owe to our office for services that have already been rendered, will be charged to your credit card and a receipt will be sent to you.This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment. Once insurance processes, we will allow 10 days for you to dispute. If you do not contact us inside of the 10 days, your card will run automatically. If you dispute after the 10 days, and your appeal is correct, we will issue a full refund to your card.Please review all of your explanations from your insurance company so you are prepared for any charges due to you.Co-pays and coinsurances are still due at the time of service.
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Proof of Insurance All patients must complete our patient information form before seeing the doctor. We must obtain a copy current valid insurance to provide proof of insurance. If you fail to provide us with the correctinsurance information in a timely manner, you may be responsible for the balance of a claim. The exception is Self Pay patients
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Non Payment You will receive a $5.00 statement charge for each statement that has to be sent. If your account is over 90 days past due, this will process to collections. Please read the following disclosure. I understand that responsibility for payment of medical services in this office for myself and my dependents is mine; due and payable at the time of services are rendered unless financial arrangements have been made. I understand that I am responsible for all costs of collection including attorney fees, collection fees of 35% and court costs. I understand that any unpaid balance will be assessed interest at the rate of 18.00% (1.5% monthly). Insurance claims are filed as a courtesy, but it is my responsibility to see that the claims are paid. I fully understand that I am responsible for payment of fees not covered by insurance. I also assign all benefits to Provider. I authorize the submission of claims without obtaining my signature on each claim submitted. I give my authorization and consent for treatment after having a full explanation of proposed treatment, alternatives, and risks by my doctor. I have been advised of my privacy rights as provided by the Healthcare Information Portability and Accountability Act of 1996. I hereby authorize Family Medicine Associates and its employees, agents, and assignees to contact me via e-mail, text messaging and to my cellular devices using automated telephone dialing systems. THESE ARE NON NEGOTIABLE
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Claims Submission We will submit your claims and assist you in any way we can to help get your claims paid. 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 insur ance benefit is a contract between you and your insurance company; we are not A part of that contract
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********NO SHOWS AND SAME DAY CANCEL ********* If you no show (do not call and cancel) or do not give 24 hours' notice you will be charged a $75.00 to $100.00 fee depending on the type of service. In addition, if you no show (do not call and cancel) three times you and your family may be released from our office. This charge can and will go to Collections if not paid.
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Surprise Billing Act Please review your rights on our website in regards to Surprise billing. We will verify your insurance prior to being seen and will give you an idea of what you need to have for your appointment. If in the appointment, you must have more services (wart, stitches, lesion removals etc.) You will billed for these seperately and will be subject to your insurance coverage. We will post our prices on our website for your review.
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COMPLETE PHYSICALS What should I expect during my annual exam?● General physical exam(including breast exam)● Pelvic exam (pap smear)● Update of life and work situation● Update of family health history (any new seriousillnesses in your family?)● Review of your healthhistory● Update of current medications, herbs, and supplements (bring list)● Evaluation of need for health screening tests based on age and personal and family history (such as mammogram, test for sexually transmitted diseases, and colon cancer screening)● Update on immunizations
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Not included in a physical exam Please be prepared to schedule a separate appointment if you have health concerns other than your routine physical exam or be prepared to pay an additional copay,coinsurance or deductible fee by your insurance company once they have processed the claim for your annual exam. Examples that may trigger these additional fees are:● A list of concerns or questions.● New healthcare concerns or problems found at the time of your annual exam.● On going health problems that need more attention.● Discussion of new or ongoing symptoms/medical concerns.Choose multiple.
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DIFFERENT TYPES OF VISITS
Virtual Visit or Online Visit Virtual or Online are "visits" initiated by the patient on the patient portal. This can be referral requests, RX refills, Change in RX. These all require the time and decision making from a Practioner. The Practioner must review your chart before any advice or items are handled. This can be anywhere from 5 minutes up to 30 minutes, depending on the request. These are chargeable services that could be subject to Patient Responsibility or not a benefit of your plan. This can generate a patient balance of 15 to 50.00 dollar charge depending on the extent of the visit
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Telehealth In the state of Colorado, you are allowed to have your visits via Telehealth. This is a Online visit with visual (camera) and Audio. These are full visits, that are billed to insurance companies and are subject to your copay, coinsurance and deductible. The list is limited on the type of visits that can be done via Telehealth, so please inquire.
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In PersonGood old fashion visit to your Practioners office. Please be aware of your benefits for each of the types of in person visits you have.i
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AUTHORIZATION TO RELEASE LAB AND TEST RESULTS TO FAMILY MEMBERS
Many of our patients allow family members such as their spouse, parents or others to call and request the results of tests and procedures. Under the requirements for H.I.P.P.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your test results released to family members you must sign this form. Signing this form will only give consent to release laboratory and radiology results to the family members indicated below. This consent form will not allow Family Medicine Associates, PC to release any other information to these family members. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. IF NO RELEASE AUTHORIZED, PUT XXXX IN THE REQUIRED FIELD
Name
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First Name
Last Name
DATE OF BIRTH (REQUIRED TO RELEASE INFO)
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Month
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Day
Year
Date
RELATIONSHIP
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CAN WE DISCUSS FINANCIAL INFORMATION WITH THIS PERSON
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YES
NO
Authorization to Leave Messages with Household Members/Answering Machine From time to time it is necessary for representatives of Family medicine Associates, PC to leave messages for patients. The purposes of these messages is to remind patients that they have an appointment, to notify the patient that the medical staff would like to discuss lab or procedure results, to leave normal results, or to ask the patient to call FMA regarding an issue or concern. The purpose of this consent is to leave messages with members of your household or on your answering machine.You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
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YES
NO
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