rbwellnessclinic.com - New Patient Registration Form

HIPAA Medical Record Release Form
Patient’s name:
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Address:

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I authorize the release of my medical record or other care information including intake forms, charts notes, reports, correspondence, billing statements, and other written information concerning my health and treatment during the period of Date to Date to be send to the following provider.

Provider’s name: Rosaly M. Diaz Torruellas, MD
Address: 2801 W Charleston Blvd. suite 200 Las Vegas, NV 89102
Telephone: 702-659-9180 Fax: 702-659-9190
Patient’s Signature:

Clear
Patient’s Name:
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Consent Form For e-Prescribe:
e-Prescribe Program:
- e-Prescribing is a way for doctors to electronically send an accurate, error free, and understandable prescription from the doctor’s office to the pharmacy. The e-Prescribed Program also includes:
- Formulary and benefit transactions - Gives the healthcare provider information about which drugs are covered by your drug benefit plan.
- Fill status notifications - Allows the healthcare provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
- Medication transaction history - Provides healthcare provider with information about your current and past prescriptions. This allows healthcare providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate compliance with prescribed regimens, therapeutic interventions, drug-drug and drug-allergy interactions, adverse drug reactions, and duplicative therapy.
Consent
By signing this consent form, you are agreeing that your provider RB Wellness Clinic, LLC may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit pay or for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to gic=ve or to deny consent may not be basis for denial of healthcare services. You also have a right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to RB Wellness Clinic, LLC to enroll me in this e-Precribe Program.
Patient’s Signature:

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Patient’s Name:
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Patient’s Name:

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Financial Responsibility Policy Agreement
Please read, initial each blank and sign where indicated - this document describes your financial responsibilities.

This is a legally binding contract between RB Wellness Clinic, LLC and you. The words I, me, my, you, and your all refer to the patient.
Initial    I agree to be financially responsible for payment to RB Wellness Clinic, LLC services. Cash, check, and credit cards are acceptable forms of payments for these services.
Initial   Current insurance cards must be presented at every office visit. RB Wellness Clinic, LLC is not responsible for filling your insurance claim, but as a courtesy we will do so. I agree to pay the remaining balance after my insurance has paid on my claim immediately upon receipt of a statement.
Initial   I agree to give The Practice my complete and accurate insurance information for primary and secondary insurance benefits including referral document from other providers, if needed. I understand that if I fail to give complete and accurate information about benefits this may result in a denial of my claim or a delay in payment. I agree to pay The Practice the balance on my account after my insurance has been processed.
Initial   I understand that I will be responsible for missed appointments or any cancelled in which a 24 hr notice was not given. There will be a fee of $50 for any missed office visits and $75.00 for any missed office procedures or physicals. There will also be a $20.00 fee for arriving 16 minutes late to your medical appointment.
Initial   I understand that there will be a fee of $30.00 for all returned checks, and that if I present a second bad check, my checks will no longer be an acceptable method of payment foe me.
Initial   I understand that all services provided to me by The Practice are considered medically necessary, if I fail to have a procedure performed or do not comply with my provider’s instructions it may be against medical advise and may void my insurance payments. Should this occur, I agree to pay the balance remaining on my account after my insurance has been processed.
Initial   If I have a high deductible policy or do not have insurance benefits. I agree to pay an estimate of charges for my office visits in advance and understand that other charges may apply.
Initial   RB Wellness Clinic, LLC has a contract with my insurance company. The Practice will receive payments from my insurance company for covered services provided by insurance benefits. I agree to pay co-payments and deductibles at the time of service. If copayment are not made at the time of service, I understand that I might need to reschedule my appointment.
Initial   I agree to pay any balance remaining on my account after any insurance payments have been paid upon receipt of a statement. I must give RB Wellness Clinic, LLC my current address and other contact information. I understand that if I fail to pay the balance on my account this may result in The Practice pursuing any collections means possible.
Initial   If my account becomes delinquent, it may be forwarded to an outside collection agency. If this happens, I will be responsible for all cost of collection, including but not limited to interest, re billing fees, court cost, attorney fees, and collection agency cost.
Initial   If the reason for my visit is related to a work related injury or auto accident, I understand that the practice won’t be able to see me, and that I will need to go wherever my attorney assign me to go.
Initial   I understand that FMLA forms have a $75 fee to be fill out when is provided with 7 days in advance. If FMLA form is provided with least 3 days prior or “rush” to be fill out and return to you there will be a $150 fee.
Initial   I understand that Medical Certificates form have a $15 fee.

I have read and I understand RB Wellness Clinic, LLC financial policies and I accept responsibility for payment of any fees associated with my care.
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