ESTABLISH PATIENT

Has anyone in your family or the father of the baby’s family had any of these?

• We would like to welcome you as a patient to Midland Women's Clinic. This form you are completing now will assist us in providing you with the best possible care. The scheduling and financial process can take up to 3-5 business days after receipt of this form. An additional email will be sent to you regarding your financial responsibility and estimation that will require a signature prior to your New OB appointment.

• All patients and attending parties must arrive 10 minutes before their appointment. If you are late, you could be re-scheduled or moved to a different time. Visits that involve Sonograms will not wait for other parties to arrive.
• Payment is required at check in. Your payment amount is based off of your benefits. Your appointment will be rescheduled if payment is not collected.
• If you need tocancel orre-schedule your appointment, please call the office atleast 24 hours prior to your appointment toavoid being billed a $50.00 no-show fee.
• We do not file Medicaid as a Primary or Secondary insurance carrier. Failure to present the correct insurance information claim denials and inaccurate calculation of payments due.

If you have any questions, please do not hesitate to call (432-699-2370 ext 205).
We look forward to starting your OB care with you!!

1. Cancellation/No Show Policy
We understand that there are times when you must miss an appointment due to an emergency or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit because the schedule seems “full”.

If an appointment is not cancelled at least 24 hrs. in advance, you will be charged a fifty-dollar ($50) no show fee; this will not be covered by your insurance company. A patient who no shows more than three times is dismissed from the practice.

2. Scheduled Appointments
We understand delays can happen however, we must try to keep the other patients and doctors on time; although sometimes our doctors do run behind, your timely arrival helps from adding to the delay.

If a patient is 15 minutes late past their appointment time, we reserve the right to reschedule the appointment(s).

3. New Patient Paperwork
We ask that all new patients have our new patient paperwork filled out and in our office at least one business day (24 hrs) prior to your appointment. Having this information ahead of time allows our staff to be able to give you the best care during your appointment.

If our clinic does not have your new patient paperwork at least one business day (24 hrs) before your appointment, we may have to reschedule your appointment.

I understand all the above policies and procedures.

Please take a few minutes to read the paragraphs below and sign in the indicated spaces:

 

1. I authorize my insurance carrier to release information regarding my coverage to Midland Women's Clinic. I also authorize agents of any hospital, treatment center or previous physicians to furnish Midland Women's Clinic copies of my medical history, services or treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation agency, or any physician or insurance carrier as needed. I also agree to a review of my records for purposes of internal audits and quality assurance reviews within Midland Women's Clinic

2. My right to payment for all pharmaceuticals, procedures, tests, supplies and nursing/physician services including major medical benefits, are hereby assigned to Midland Women's Clinic. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to Midland Women's Clinic within five business days.

3. I authorize Midland Women’s Clinic to obtain/have access to my medication history.

I am also aware of this office's Notice of Privacy Practice and HIPAA/Privacy policy which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Effective January 1, 2024, CMS (The Centers for Medicare and Medicaid Services) approved the use of CPT code 99459 to help with the ever-increasing costs of providing healthcare to women, specifically the costs associated with pelvic exams and the need for a chaperone for most of our exams.

Using CPT language, this code is considered a practice expense add-on code and is added to your Evaluation and Management (E&M) or problem visit, or your Well Women visit when a pelvic examis performed with a chaperone present. Based upon your benefits plan, this code may be paid at 100% or it may be subject to deductibles, co-pays, or co-insurance resulting in an out-of-pocket expense.

As you may be aware, the availability of quality women's healthcare has become more and more difficult to find. This issue, which is seen in most specialties, has been made worse by the high incidence of retirements following the public health emergency caused by Covid.

Our goal is to continue to serve you, our valued patients, despite ever decreasing Medicare reimbursement as well as double digit inflation. Please understand, while we are seeing this covered by the major commercial insurance carriers there could be patient responsibility. 

Thank you.