Women: Are you.....

Information of Insurance Policy Holder

(if self, skip section)

In the last year visited:

FOR FEMALES ONLY:

Referral Process
It may be necessary for our office to refer you to a specialist to manage your care. In order for a referral to be made, you must be evaluated first in our office. If you need to request a referral from us, phone us at least one week prior to your appointment. As part of the referral process, we may need to share your medical information with another provider or specialist. Your privacy is protected as only minimal information is shared.

Medication Refills
Please bring your medications to your appointments. Should you need refills prior to your next appointment, first call your pharmacy. They can request a refill from our office. Please give us at least 1 week notice prior to your medication running out, 2 weeks’ notice if it is a mail-order pharmacy. Pain medicines may require an appointment.

Billing
Please bring your insurance card(s) to each visit. All co-pays and deductibles are the patient’s responsibility and expected to be paid on the day of service prior to being evaluated by the provider.

• If a patient has a no-copay/high-deductible plan, then the patient is expected to pay $65 that will go towards their office visit at the time of service or, if known by the provider, the full contracted insurance rate for the office visit at the time of service.
• If the patient needs the provider to complete paperwork (e.g. FMLA paperwork) outside of an office visit, then a $35 fee is required for completion.

Scheduling Appointments
Patients are seen by appointment only, except in the case of an emergency, which may cause delays. We ask for your understanding, knowing that if you ever require urgent care, we will give you prompt attention. To schedule appointments, please call (330) 422-4377. In the event that you are unable to keep your appointment time, please call at least 24 hours in advance to reschedule. There will be a $50 charge for no show appointments. If you miss 2 or more appointments due to a “no show” appointment, your chart will be reviewed and you may be discharged from this practice.

Hospital/Emergencies
If you have a life threatening illness, call 911 or go to the nearest Emergency Room and have a family member call our office.

After Hours/On Call Policy
Our office hours are Monday through Friday 9am-5pm. For urgent request, please contact our main office number rather than Spruce. If it is an urgent request and we are unable to address your concern, please go to the emergency department as soon as possible. For non-urgent request, you can leave a message for staff to be returned within the next 3-5 business days. 

UH Twinsburg Urgent Care - 8819 Commons Blvd., Suite 101, Twinsburg, Ohio 44087 P: 234-837-5418 

Cleveland Clinic Emergency Department - 8701 Darrow Rd, Twinsburg OH 44087 P:330-888-4176

By signing on the next page, I agree to the above policies.

Please read and sign at the bottom to agree to the following statements:

I hereby authorize the release of medical information to insurance carriers, referring providers, and healthcare systems concerning my illness and treatment, when necessary. I hereby assign to the doctor all payments for medical services rendered to me or my dependent. I understand I am responsible for any amount not covered by insurance.

Acknowledgement of Treatment
I request and authorize Dr. Aarondeep Deol, Dr. Nazmine Deol, staff, and resident physicians, to perform general treatments and procedures as may be deemed necessary in my care.

Notice of Privacy Practices Acknowledgement
I, the undersigned, acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read, or have been offered a copy, and understand the notice (available upon request).

Medicare One Time Direction of Payments
If applicable, I give my permission to ask for Medicare payments for my medical care. I understand that Medicare needs information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment requests. I understand that the Health Care Financing Administration (HCFA) is the government Medicare agency.

By Signing here, I state that the above information has been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health.