New Patient Intake Form

I hereby authorize my physician to furnish to my insurance carriers a record of my illness and treatments, including any documentation they may request.

I hereby assign to my physician all payments for medical services rendered to myself or my dependents until revoked in writing. I understand that I am responsible for any amount not covered by insurance at the time of service. I also understand that I am responsible for collection and legal costs should it be necessary for this account to be turned over to collection agency.

Dr. Ross is a contracted PPO provider with many insurance plans, including, but not limited to Anthem Blue Cross, BlueShield, United Health Care, Aetna, Beech Street, First Health, Health Net, Humana, PHCS and Cedars‐Sinai Health Associates HMO.

However, this does not ensure coverage under your particular plan. As  such, patients are responsible for confirming their own insurance benefits. You will be responsible for any payments denied by your insurance carrier.

Some or perhaps all of the services rendered may not be considered reasonable and necessary by your insurance carrier under your plan. In this instance, as the responsible party, you will be responsible for all charges your insurance carrier declines to pay for any reason.

Dr. Ross is NOT  a provider for any insurance plans provided by the Affordable Care Act or Covered California.

Other payments that are patient responsibility, regardless of your insurance carrier, will include: co payments, co‐insurance, deductible and disallowed portion of any services.

Please sign below as your acknowledgement and understanding of this policy.

Should you have any questions, please feel free to ask our billing office.

• HIPAA stands for the Health Insurance Portability and Accountability Act
• HIPAA was passed by the U.S. government In 1996 in order to establish privacy and security protections for health information
• Information stored on our computers is encrypted
• Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA
• The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website ‐ http://www.gpo.gov/fdsys/pkg/FR‐2013‐01‐25/pdf/2013‐01073.pdf
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email

I understand the risks of unencrypted email and do hereby give permission to the office of Dr. Samuel Ross to send me  personal health information via unencrypted email

 

We strive to provide excellent medical care to you and all of our patients. In order to do so effectively and efficiently, we have developed an appointment system that sets asides ample time for a patient.

“No‐shows", and late cancellations inconvenience those individuals who need access to medical care in a timely manner. In an effort to reduce the number of such occurrences, we have implemented a Medical Appointment Cancellation Policy.

Our policy is as follows:

1. We request you give our office a 24‐hour notice in the event you need to reschedule your appointment.
2. If you miss an appointment and do not contact us with at least a 24 hour prior notice, we will consider this a missed appointment and a $100.00 no-show fee will be assessed to you. This applies to late cancellations and "no-shows." Subsequent missed appointments and late cancelations will have a fee of $200.
3. If you are late for an appointment, you will be seen as soon as possible, though the office visit may need to be shortened in length.
4. If you are more than 10 minutes late, your appointment may be rescheduled. 
5. Our office sends reminder emails for appointments. However, it is ultimately the patient's responsibility to remember their scheduled appointments.

This fee will be billed to you directly and is not covered by your insurance. This balance must be paid prior to your next appointment. If you don't have a scheduled appointment, the balance is expected in a timely fashion.