New Patient Packet - 2025 Update

Financial Responsibility: All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments. Patient understands that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.*
Assignment of Benefits: Patient hereby assigns all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) directly to Metro North Cardiovascular and Associates P.A. / Max Gerald Garoutte, M.D. for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. Patient understands that he/she is responsible for any amount not covered by their insurance plan.*
Authorization to Release Information: Patient hereby authorizes Metro North Cardiovascular and Associates P.A. to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated during examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing. Patient has requested medical services from Metro North Cardiovascular and Associates P.A. / Max Gerald Garoutte, M.D. on behalf of patient and/or dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. *
Medicare Lifetime Signature: Patient hereby assigns that payment of authorized Medicare benefits be made on my behalf to Metro North Cardiovascular Associates, P.A./ Max Gerald Garoutte, M.D. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information*
HIPAA Compliance Metro North Cardiovascular Associates, P.A. is committed to securing the privacy of your health information. If you wish to obtain a copy of the practice's "Notice of Privacy Practices", notify our staff. Patient acknowledges that while they are not required to read the "Notice of Privacy Practices" document, it can be made available upon request. PLEASE SIGN AND DATE BELOW TO ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND EACH OF THE ABOVE-MENTIONED CONSENT TOPICS.*
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Garoutte Medical Associates - Max G. Garoutte, M.D.

GMA is legally obligated to abide by the laws and regulations as defined by patient's insurance companies.

Office Visit Responsibility: Patients are required to provide insurance and ID card during check-in of every visit. Patients must fill out all forms completely prior to being seen by the doctor. Patients are expected to have forms filled out prior to appointment time. Failure to have forms filled out prior to appointment time may result in delays. Patients are responsible for all appointment costs prior to services rendered, including but not limited to copays and deductibles. Bring an updated copy TO EVERY APPOINTMENT including all medications, vitamins and supplements including the dose and frequency of the medication(s) you take. Preparing medication list at home, prior to appointment, with medication bottles in front of you, is best way to accurately compile this information and will result in expedited visit times. Allow up to 48-72 hours for any medication refills. Give our office as much notice as possible to ensure you have enough medication to see you through. Do not wait until the last day to request a refill. Keep all scheduled appointments with the Provider to ensure your medication refills will be approved. We cannot refill medications for patients who do not follow-up with the Provider for a required face-to-face consultation. Our office calls patients the day prior to their scheduled appointment. Please be sure to check your voicemail frequently in case we have contacted you regarding appointment times. Be sure to confirm your appointment in the event we are unable to reach you, in order to ensure your appointment time has not changed for any reason. Be sure to schedule appointments with plenty of time, in advance, for any scheduled surgeries or procedures in which you may be required to obtain a preoperative cardiac clearance. More than likely you will be required to have some type of cardiac testing prior to being cleared and must follow-up with the Provider in order to be cleared for such surgeries/procedures.

Financial Responsibility: Patient is required to pay your office visit in full prior to services rendered. All past due balances are due prior to you being seen for your appointment. $50 for all 1-2-page FMLA and or Disability forms must be paid at the time request is made. $100 for all 3+ page FMLA and or Disability forms must be paid at the time request is made. $200 fee for all medical necessity letters written by the Provider. Please allow up to 10 business days for all form/letter requests to be fulfilled. $25 fee for a printout of any billing ledgers (i.e.: account history, payment history, copies of billing statements, etc The fee is due prior to receiving the ledger. Please allow up to 48 hours for this to be made ready. $25 fee to fill out any health forms (i.e., wellness forms, clearance for full-duty, or return-to-work/school forms, health insurance form, sports or camp participation $50 administrative fee for any rushed requests on medical records, or any other documents. $25-$50 fee (pending appt type) for all missed/no show appointments or if the appointment is not canceled with a 24-hour notice. At the third incident, the Practice will send your PCP a letter of non-compliance or failure to follow-up and the Practice may choose to dismiss you as a patient. Monthly statements are mailed out for balances at the beginning of each month, and are due within 30 days of the statement date. If there are any disputes, concerns and or questions please contact the billing department immediately or in order to avoid your account being referred to collections. There is a fee for medical records you wish to hand-carry yourself to another physician and or wish to have for your personal file. The fee is $25 for pages 1-20, and $0.50 for each additional page thereafter. $50 fee for a C.D. of an Echocardiogram, Carotid Doppler, Venous Doppler, Abdominal Aortogram and Stress Echocardiogram you wish to have, prior to the C.D. being made. I have read the above financial policy for Garoutte Medical Associates., and I agree to the terms and conditions contained herein, assign all insurance benefits, if any, otherwise payable to me for services rendered directly to GMA. I understand that I am financially responsible for ALL charges whether or not paid by the insurance. I hereby authorize, GMA, to release all information necessary to secure payment of benefits.
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Garoutte Medical Associates, P.A.