Registration Form

I have completed this form to the best of my knowledge and I understand I am to contact the office with changes to my personal information. I understand that I am responsible for all outstanding patient liabilities and financial obligations.

If Patient has a Legal Guardian, a copy of the legal document granting you such power must be attached or on file with office.

Scoring GAD-7 Anxiety Severity

This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories,
respectively, of “not at all,” “several days,” “more than half the days,” and “nearly
every day.” GAD-7 total score for the seven items ranges from 0 to 21.

0–4: minimal anxiety
5–9: mild anxiety
10–14: moderate anxiety
15–21: severe anxiety

In an effort to provide better care to our patients, we have adopted the following policy changes as well as some reminders. Please carefully read and initial each item and sign where indicated.

I thank you for the opportunity to care for you and look forward to our continued professional relationship.

 

By signing this I am attesting that I understand the updated policies.

Financial and Billing Policy

Lumea Primary Care Center LLC is committed to providing our patients with the best possible medical care and treatment. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

 

Insurance

Your insurance is a contract between you, the patient, and the insurance company. We will submit the insurance claims on your behalf. It is the patient’s responsibility to inform the office of any changes to your insurance coverage.

Co-Pays: Co-pays are due at the time of your visit, and they cannot be waived. Your are responsible for paying the amount indicated by your insurance company.

Deductibles: Some insurance plans have deductibles. The deductible amount varies based on the insurance plan and/or insurance company. The deductible is the patient’s responsibility and insurance will not cover any benefits until it is reached and paid by the patient.

Uncovered Services: Please be aware that some office visits, labs, testing, medication, and any other medical miscellaneous procedures may not be covered with your insurance coverage. Therefore, it is the patient’s responsibility to understand their insurance benefits and financial responsibilities. Patients are responsible for payment of services rendered and not covered by insurance.

Appointments

We strive to provide the best care in a timely and efficient manner. We will call, text, or email you to remind you of your scheduled appointments. If you need to change or cancel any appointments please do so, as soon as possible. We require at least a 24-hour notice to change or cancel appointments. We will assess a $50.00 fee for any appointment that results in a no call no show. A $25.00 fee if you fail to adequately give 24-hours notice.

 

 

Payment Policy

Lumea Primary Care accepts cash and credit/debit cards (3.99% fee applies).

• We are in-network with: Medicaid, Medicare, AmeriHealth, Blue Cross Blue
  Shield, Tricare, Cigna, and Independence.
• Patients are responsible for paying deductibles, co-pays and co-insurance at the time of visit.
• If you do not have insurance, you will be required to make payments at every
  visit.
• I understand that the cost of medication and other treatment(s) are not included in this policy—only services provided by Lumea Primary Care Center.
• I understand the conditions of this Payment Agreement and agree that my
  account must remain current.
• I understand that failure to pay fees on time will violate this Payment Agreement.
• I understand that a violation of this Payment Agreement may result in termination from the program and all services discontinued.

 

Definitions

Co-payments, Co-insurance, and deductibles. Most insurance plans have cost sharing elements, in which the patients are required to pay portions of their care. If a patient does not pay these amounts, the insurance will not pay for these services. Co-payments, co-insurance and deductibles must be paid at the time of service.

Proof of insurance. All patients must complete our patient information form before seeing the provider. We must obtain a copy of your driver’s license and proof of valid active insurance.

Claims submission. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Claims denied due to the insurance company requesting information from you will be your responsibility.

Client Rights and Responsibilities Statement

Statement of Client’s Rights

• Clients have the right to be treated with dignity and respect.
• Clients have the right to fair treatment regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
• Clients have the right to have their treatment and other client information kept private. Only where permitted by law, may records be released without client’s permission.
• Clients have the right to share in developing their plan of care.
• Clients have the right to information in a language they can understand.
• Clients have the right to have a clear explanation of their condition and treatment options.
• Clients have the right to information about their provider, services and their role in the treatment process.
• Clients have the right to ask their provider about their work history and training.
• Clients have the right to know of their rights and responsibilities in the treatment process.

 

Statement of Client’s Responsibilities

• Clients have the responsibility to treat those giving them care with dignity and respect.
• Clients have the responsibility to give the provider the information they need. This is so the provider can deliver the best possible care.
• Clients have the responsibility to ask questions about their care.
• Clients have the responsibility to follow the treatment plan. The plan of care is to be agreed upon by the client and provider.
• Clients have the responsibility to follow their prescribed medication regiment.
• Clients have the responsibility to tell their primary care provider about medication changes, including medications given to them by others.
• Clients have the responsibility to keep their appointments. Clients should call their provider as soon as possible if they need to cancel their appt.
• Clients have the responsibility to let their provider know when the treatment plan isn’t working for them.
• Clients have the responsibility to report abuse and fraud.
• Clients have the responsibility to openly report concerns about the quality of care they receive.

 

My signature below shows that I have been informed of my rights and responsibilities, and that I understand if this information.

Consent to Treatment

I acknowledge that I have reviewed, discussed and understand the information about the
treatment I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the treatment by the provider named below. I
understand that developing a treatment plan with this provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any
procedures provided by this provider.

I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I may be charged for that appointment.

My signature below shows that I understand and agree with all of the above statements.

Informed Consent for Laboratory Services

By signing below, you certify that you have read and understand this Patient Informed Consent for Laboratory Services in its entirety, and herby consent to providing specimens of your urine, blood, or other bodily fluids to our office and/or LabCorp for laboratory testing, as appropriate, for the diagnosis and treatment of substance use disorder (SUD) and other conditions as identified by the provider.

During the duration of your care, the practitioner will order certain laboratory tests for purposes related to your medical care and treatment. We utilize LabCorp for all our testing. If your insurance utilizes Quest, please inform our staff so we can send your specimen and/or lab work there. LabCorp or Quest may charge for services rendered, this is contracted between your insurance company and LabCorp.

Urine Drug Screening (UDS)

We use urine drug screens to evaluate, assess, and manage a patient’s condition. UDS can improve your provider’s ability to screen for and detect substance use, including prescription drug misuse, abuse, and diversion; diagnose and treat substance use disorders; manage chronic care for substance use disorders to support and sustain recovery; and direct therapy with prescription drugs.

You are required to provide samples of your urine for drug testing, including random testing, to receive treatment.

If your test results are negative for a prescribed medication or positive for nonprescribed medications or illegal substances, it is considered a positive result and the provider may adjust your treatment plan, including safe discontinuation of your medication, terminate your treatment, or refer you to another treatment provider. Any refusal or inability to provide a urine sample will be treated as a positive result. No medication can be prescribed without a UDS.

Other Laboratory Testing

Early detection and treatment are generally associated with better outcomes. Many conditions can be detected and treated by your prescribing provider and the tests we recommend are useful to help improve your health and to ensure that you are free of
conditions commonly observed among individuals with a history of substance use disorder. It is well documented that individuals with substance use disorders are at an increased risk for certain medical conditions, including hepatitis, human immunodeficiency virus (HIV), sexually transmitted infections (STI), hormone imbalances, liver disease, and kidney disease because of illicit substances, prescribed medications that have been taken in ways other than directed. All lab results usually
take 3 business days to be available, at that time the office will forward you a copy, and the provider will call you to discuss the results.

Consent for Release of Confidential Information

This consent allows Lumea Primary Care Center LLC to bill services to your insurance provider, and to communicate with and disclose to one another the following information to any Third- Party Payor (Commercial Insurance Company/Medicaid/Medicare/etc.) related to my care Lumea Primary Care Center LLC for the purpose of Billing and Collection.

Complete Patient Record for Billing and Collection, including progress reports, chart notes, urine drug testing results, lab tests, treatment plan, demographics, verification of funding source(s), and billing documentation.

I authorize Lumea Primary Care Center LLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered.

I understand that my alcohol/drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I acknowledge that the information to be released was fully explained to me and that this consent is given on my own free will and that by signing I have reviewed and understand the terms of this consent. I understand that I will be provided a copy of this document at my request.

HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication.

You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserves the right to change the privacy policy as allowed by law.

• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.

• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

• The practice may condition receipt of treatment upon execution of this consent.

Please be advised that any person not referred to on this list will not be given any information related to your care, including billing information. You may change, restrict, or expand this listing at any time.

You are not required to list any name(s) if you do not choose to.