Treatment Authorization
I request and authorize medical or surgical treatment as may be deemed necessary and appropriate by the physician and his/her assistants participating in my care. This care may include: diagnostic, laboratory or radiology procedures; anesthesia, therapeutic procedures, nursing, hospital or blood transfusions. I understand I will sign an informed consent IF surgery or surgical procedure is recommended.
Release of Information
I authorize Vascular & Endovascular Associates, PLC to release pertinent information and/or copies of medical records for treatment, payment or health care operation purposes. I understand such information may include Human Immunodeficiency Virus (HIV), AIDS Related Complex (ARC) and Acquired Immunodeficiency Syndrome (AIDS), Hepatitis, substance abuse, psychiatric/psychological services records and social work records, if any. See notice of Privacy Practices for further information.
Payment
I assign and authorize payment from my insurance company directly to Vascular & Endovascular Associates, PLC Professional Services for any and all services rendered. I agree to pay, at the time of completed services, all charges not covered by my insurance company. I understand that it is my primary responsibility to pay all charges for services rendered irrespective of any disputes or disagreements between myself and the insurance company.
Communication
I agree to receive communications from Vascular & Endovascular Associates, PLC related to my bills and treatment through text messages, emails, and physical mail. I understand that these communications may include information about my appointments, billing statements, payment reminders, and other related notices. I acknowledge that it is my responsibility to keep my contact information up to date and notify Vascular & Endovascular Associates, PLC of any changes.
No Guarantees
I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees or promises have been made to me as to the results of the care and treatment which I have hereby authorized. I release Vascular & Endovascular Associates, PLC all responsibility for personal articles which I have with me during the time I am a patient. I understand the office is not responsible for personal articles of value kept in my possession while a patient at the office.
Acknowledgement of HIPAA Privacy Notice
I reviewed a copy of the Notice of Privacy Practices. I have read this form, or it has been read to me and I am satisfied that I understand its contents. I further understand that this content will be deemed continuing and I am free to withdraw my consent at any time.
Prescription of Narcotic Medication
PLEASE PLAN AHEAD! We cannot accommodate same day requests for pain medication.
Beginning June 1, 2018, due to new government regulations, all narcotic prescriptions require practitioners to check and update the Michigan Automated Prescription System (MAPS) prior to prescribing a narcotic medication. Some of the changes to the prescription of narcotic medications include the following:
- Requests may be made only during regular office hours (8:00 AM to 4:00 PM), Monday through Friday or during regularly scheduled office visits.
- Refill requests will not be honored on nights, weekends, and holidays.
- Narcotic prescriptions cannot be written for more than a 7-day supply.
- Requests will not be honored if patients run out early, lose a prescription, or spill/misplace medications.
- Only written prescriptions will be given and no narcotic prescriptions will be telephoned or faxed to the pharmacy.
- Refill requests for narcotic medications require at least 3 business days (72 hours) notice, to allow enough time for the provider to check and update the Michigan Automated Prescription System (MAPS)
To help both providers and patients to comply with the law regarding narcotics, patients will be required to sign an Informed Consent acknowledging that:
- They have received information regarding the danger of opioid addiction.
- How to properly dispose of unused controlled substances.
- Delivery of a controlled substance is a felony under MI law.
- Short-and-long term effects of exposing a fetus to a controlled substance.
All Other Prescription Refills
- We require at least a 72-hour (3 business days) notice for refill and prescription requests. Please plan accordingly.
- We also encourage you to contact your pharmacy before going to pick up your prescription to make sure it is ready.
Cancellation/No Show Policy for Doctor Appointment or Ultrasound
We understand that there are times when you must miss an appointment due to emergencies 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, due to a seemingly “full” appointment book.
If an appointment is not cancelled at least 24 hours in advance you will be charged a seventy-five dollars ($75) fee; this will not be covered by your insurance company.
Scheduled Appointments
We understand that delays can happen however we must try to keep the other patients and doctors on time.
If a patient is 30 minutes past their scheduled time, we will have to reschedule the appointment.
Cancellation/No Show Policy for Surgery or Sclerotherapy
Due to the large block of time needed for surgery, last minute cancellations can cause problems and added expenses for the office.
If surgery is not cancelled at least 3 days in advance you will be charged a one-hundred-fifty dollar ($150) fee; this will not be covered by your insurance company.
Account Balances
Patients who have questions about their bills or who would like to discuss a payment plan option may call and speak to a billing representative who can review their account and concerns.