Authorization to release medical information and assignment of insurance benefit.Initial* I authorize the release of any medical information necessary to process my insurance claim(s) and assign all medical and/or surgical benefits including major medical benefits, to Fort Wayne Primary Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. Even though I have provided all my insurance information, I understand that I may be financially responsible for any balance not covered by my insurance. I agree to provide my most current insurance information and if any bills are not paid by the insurance because of outdated or inaccurate information, I agree to pay my entire bill in full - even though the bill might have been paid by insurance had I provided the correct information. I understand that holistic treatments are not a substitute for medical diagnosis and treatment, and no medical claims are made regarding these treatments.Financial AgreementInitial* All Fort Wayne Primary Care account balances are due at the time of service. I understand and agree that (regardless of insurance coverage), I am ultimately responsible for any professional service rendered. I certify that this information is true & correct to the best of my knowledge. I will notify you of any changes in my insurance coverage, address, or health status. I accept this statement as notice from you that my insurance plan may not pay for any service that you provide to me because the service or procedure may not be covered by the plan or may not be considered medically necessary by the plan. I agree that all services and procedures that I receive from you have been requested by me with full knowledge that my insurance plan may not cover them.Late PaymentsInitial* All past-due account balances may be assessed a late payment fee equal to 18% per annum on the delinquent balance. A late payment fee can be avoided by paying the account balance within 30 days of the mailing of the patient statement. Subject to such limitation as may be imposed by applicable law, if I have not made payment on my account as required, my account may be sent to an attorney or collection agency for collection, I will pay the reasonable fees of such attorney or collection agency, and all court costs to the extent provided by law as well as my total outstanding bill. No waiver by Fort Wayne Integrative Medicine or Fort Wayne Primary Care or any default hereunder shall constitute a waiver of any other default. The construction and enforcement of this Agreement shall be governed by the State of Indiana. Any Provision of this agreement that may be prohibited by law shall be ineffective only to the extent of such prohibition. From time to time, Fort Wayne Primary Care may amend this Agreement by giving of such notice, if any, as may be required by applicable law. Fort Wayne Primary Care may assign the Agreement, or it's right hereunder, without notice to me.Payments due at time of serviceInitial* I understand that, at the time of service, there will be a minimum charge equal to my copay amount.No-show/Cancellation policyInitial* When you make an appointment, we are reserving time in our clinician's schedule that is no longer available to other patients. If you are unable to make it to an appointment, Fort Wayne Primary Care requires that you cancel (or re-schedule) your appointment at least 24 hours in advance (1 business day) excluding weekends and holidays. If you cancel an appointment with less than a 24-hour notice or fail to appear in a timely fashion for an appointment, Fort Wayne Primary Care will charge the patient $25.00. This applies to new patients as well. Failure to show for your appointments (or violation of this cancellation policy) on two or more than two consecutive occasions can be grounds for discharge from the practice. Note that the cancellation fee may be waived in special circumstances, determined on an individual basis (i.e., medical emergency-patients may be asked to provide documentation for the same).Consent to careInitial* I request and give consent to Dr. Veerula, the nurse practitioners, their associates and assistants who may provide me medical care to perform such medical-surgical care, tests, procedures, and other necessary services as well as provide drugs and supplies as they consider necessary or beneficial for my health and well-being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me. In addition, I understand there may be adverse effects or complications from some treatments/procedures/drugs, etc.
Self-Pay Laboratory ServicesInitial* We ask that all patients pay upfront if administering these specific lab requests. These lab requests are routinely denied payment by insurance companies. If the patient refuses cash payment for Lipoprotein A, Homocysteine, Vitamin D, Ferritin, hs-CRP, Fort Wayne Integrative Medicine or Fort Wayne Primary Care will not facilitate insurance coverage, CPT codes or the balance due after labs have been drawn and processed by the patient's insurance.
For Medicare patients only:Statement to permit payment of Medicare benefits to provider, physicians, and patients. I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished to me by Fort Wayne Primary Care, including physician, nursing, or lab services. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits or benefits for related services.Signature Date
HIPAA Privacy receipt acknowledgementDate: Date* Fort Wayne Primary Care, LLC's "Notice of Privacy Practices" has been offered to me. It is available from the front desk of the Fort Wayne Primary Care Office, LLC as well as on the website ( WWW.FWIMED.COM) I understand I have the right to review the 'Notice of Privacy Practices' prior to signing this document. By signing this document, I acknowledge my receipt of an agreement with an understanding of the above-mentioned privacy practices.Fort Wayne Primary Care reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.Updated 'Notice of Privacy Practices' is available at the front desk or on the website.
OFFICE USE ONLYThe above-named patient or personal representative of the patient was given Fort Wayne Integrative Medicine, Fort Wayne Primary Care & V. Veerula MD, LLC's Notice of Privacy Practices on the date indicated, but either refused to sign this acknowledgment or did not return the acknowledgment.Signature Type a label Signature and Title of person providing the Patient Notice of PrivacyDate Date