PATIENT INTAKE FORMS

Please read and Sign: The above information is correct to the best of my knowledge. I understand throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.

PLEASE READ AND SIGN: The information on my intake forms is correct to the best of my knowledge.  I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above.  (Release of Information): I authorize the release of any medical information necessary to process this claim.  (HIPAA PRIVACY): I acknowledge that I received my HIPAA Privacy Practice Notice.  (Medication History): I authorize the Doctor’s office to retrieve my mediation history.

Vascular:

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge.  I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.

Your understanding of our financial policies is an essential element of your care and treatment.   If you have any questions please discuss them with our front office staff or supervisor.

• As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.
• Unless other arrangements have been made in advance by you or by your health insurance carrier, payments for office services are due at the time of service.  We accept VISA, Mastercard, Discover, cash or check
• Your insurance policy is a contract between you and your insurance company.  As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor.  In other words, you agree to have your insurance pay the doctor directly.  If your insurance company does not pay to the practice within a reasonable period, we will have to look to you for payment.
• We have made prior arrangements with certain insurers and other health plans t accept an assignment of benefits.  We will bill those plans with which we an agreement and will only require you to pay the co-pay/ co-insurance/ deductible at the time of service.
• If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis.  This means your insurer will send the payment directly to you.  Therefore, all charges for your care and treatment are due at the time of service.
• All the health plans are not the same and do not cover the same services.  In the event your health plan determines a service to be “not covered”, or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered.
• You must inform the office of all insurance changes and authorizations/ referral requirements.  In the event the office is not informed, you will be responsible for any charges denied.
• For most services in the hospital, we will bill your health plan.  Any balance due is your responsibility.
• There are certain elective surgical procedures for which we require pre-payment.  You will be informed in advance if your procedure is one of those.  In the t even, payment will be due on e week prior to surgery.
• Past due accounts are subject to collection proceedings.  All cost incurred, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.
• There is a service fee of $30.00 for all returned checks.  Your insurance company does not cover this fee.

We may use and disclose your PHI (private health information) in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.  We may also disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute. We may use or disclose your PHI for workers compensation and similar programs. We may use a sign-in sheet at the front desk and we may call you in to see the doctor by name. We may contact you my mail or phone at your residence, to remind you of appointments or to provide information about treatment alternatives.  Unless you instruct us otherwise, we man mail you a post card reminding you to make an appointment and we may leave a message for you on any answering devises or with any person who answers the phone at your residence. You can make a reasonable request for us to use alternative methods of communicating with you in a confidential manner.  These requests must be submitted in writing in a clear and concise fashion.  We are not required to agree to your request.  However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when information is necessary to treat you.

Rights that you have:

You have the right to request restrictions on some of the uses or disclosures described above.  Except as stated, we are not required to agree to such restrictions. You have the right to inspect and obtain copies of your medical information.  (A fee for the costs of copying, mailing, labor and supplies associated with your request will be charged.) You have the right to request amendments to your medical information.  Such requests must be in writing, and must state the reason for the requestee amendment.  We will notify you as to whether we agree or disagree with the requested amendment, we will further notify you of your rights. You have the right to request an accounting of any disclosure we make of your medical information except for disclosures that we make to you, to carry out treatment, payment or healthcare operations, as requested by you written authorization, as permitted or required under 45 CFD 164.502, for emergency or notification purposes, for national security or Intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law. You have the right to receive a copy of this notice. To obtain a paper copy of this notice, please contact our office manager. You have the right to file a complaint if you believe your privacy rights have been violated.  You may file a complaint with your practice or with the Secretary of the Department of Health and Human Services.  All complaints must be submitted in writing and addressed to this office at the above address.  You will not be penalized for filing a complaint. This privacy policy is subject to change as circumstances dictate.  Any changes will be effective upon release of a revised privacy policy, which will be made available to patients upon request.

Please sign and date below, acknowledging that you have read this policy and that you consent to the terms of our privacy policy as stated in this notice.

I understand that:

I do not have to give my permission to share these records.

If I want to take away the permission for my doctor to get these records, I need to talk to the doctor or a staff person and sign a paper.

This form is only good for 3 months from the date I sign it.