GENESIS Wellness Clinic - Patient Registration

Administrative Simplification

Administrative Simplification section of this Act is of Concern to our practice and requires us to comply with specific rules regarding:

1. Unique Identifiers for health plans, providers, individuals and employers.

2. Healthcare Transactions & Code Sets for transmitting electronic data.

3. Privacy Regulations over disclosure and use of health information.

4. Security Regulations over protections of electronic health information.

All of these rules have been developed by the Department of Health & Human Services and will become final in a staged manner. It will be the policy of Genesis Medical Clinic to release confidential information with signed consent by home telephone, answering machine, work telephone, voicemail and cellular phones. Whenever returning telephone calls and the answering machine picks up, it is our policy NOT to leave confidential information if there is no recorded message identifying the residence. Confidential information will NOT be left with an unauthorized person who may answer your telephone. If you would like to have your medial information released to someone other than yourself, please complete the following: I authorize Genesis Medical Clinic to leave medical information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes.

In order for us to be able to continue to deliver high quality of care, it is necessary to provide you with financial policy. PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.

1. Please present your insurance card(s) at each visit. It is your responsibility to provide us with the correct information so that we may submit to your insurance. Failure to do so may make you liable for denied claims.

2. Please present your insurance card(s) at each visit. It is your responsibility to provide us with the correct information so that we may submit to your insurance. Failure to do so may make you liable for denied claims.

3. If we do not participate with your insurance, we will file your claims as a courtesy and ask that you follow-up to make sure payment is made to us in a timely manner. If we do not receive payment from them within 45 days, you will be billed for any unpaid balance, AND 1.5% monthly interest will begin to accrue on your account. Balances are expected to be paid in full within 30 days. If payment on your account is not done in a timely manner, your account may be referred to a collection agency and reported to the credit bureau.

4. MEDICARE PATIENTS: We will submit to Medicare for all your covered services. If you have a supplemental insurance, we will also submit that for you as a courtesy. If payment is not received from your supplemental insurance within 30 days of being submitted, we will ask for the balance due. If you do not have a supplemental insurance, your portion (20% of amount allowed by Medicare) will be collected at the time of service. Each year you will be expected to pay the allowed amount of your charges until your Medicare deductible is met.

5. MEDICAID PATIENTS: We are not participating providers with Medicaid. We ask that you pay for your services at the time of your visit.

6. HMO-PPO PATIENTS: If we participate with your plan, we will submit your services to your insurance for you. Your co-payment will be collected at the time of service—no exceptions. If your plan requires you to choose a primary care physician, it is your responsibility to make sure your insurance company has the physician you are seeing in our office as your PCP. If your plan requires you to have an authorization to see a specialist, you will need to obtain that from our office prior to seeing the specialist. 72 hours notice is required to obtain all referrals. We cannot obtain retroactive referrals. If we do not participate with your plan, we will verify your out-of-network benefits, file your services, and we expect payment of your portion of the services at the time of your visit.

7. SELF-PAY PATIENTS: Patients without insurance coverage will be expected to pay at the time of service. If you will not be able to pay in full, you must contact our billing department prior to seeing the doctor to make payment arrangements.

8. NO SHOW OR MISSED APPOINTMENTS: We understand there may be times when you are unable to keep an appointment. 24 hours notice must be provided to prevent incurring a cancellation fee. If two appointments are missed without proper notice you will be charged a $25.00 fee for routine visits and

$50.00 for physicals. Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your services.

If you have any questions regarding our financial policy, please contact our billing department or practice administrator.

I, the undersigned, hereby consent to the following Treatment:

•  Administration and performance of all treatments

•  Administration of any needed anesthetics

•  Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient

•  Use of prescribed medication

•  Performance of diagnostic procedures/tests and cultures

•  Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designees

I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I understand that Genesis Medical Clinic may include consent at satellite offices under common ownership.

I, the undersigned, acknowledge that Genesis Medical Clinic will use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

Consent for Insurance Policy:

Genesis Medical Clinic will submit claims to the insurance companies that they are contracted with. I understand that I am responsible for all deductibles, copays, and charges not covered by insurance at the time of service. I also understand that I will need to bring my Insurance card at each visit along with my cost that the insurance does not pay.

MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to Genesis Medical Clinic.

I acknowledge that I have been given the Genesis Medical Clinic Notice of Privacy Practices. I understand that if I have questions or complaints that I should contact the Privacy Official. Patient Initial:

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

This office provides only outpatient services. Therefore, doctors will not be available after hours, weekends or holidays. Should you have an emergency, you must contact your primary care physician, go to the nearest hospital emergency room or call 911 

If you do not have a primary care physician you should endeavor to obtain one. The physicians in this practice will provide evaluations and treatment exclusively for those patients with neurological and pain disorders and weight loss management. They will not admit any patients to a hospital.

I have read and completely understood the above statement. I agree to consult a primary care physician for all other medical concerns.

Please answer the following Government Question: