New Patient Application

Guarantor

-Financially responsible person that will receive statements and any billing information.
Guarantor's Full Name*

First NameLast Name
Guarantor's Gender*

MaleFemale
Guarantor's Relationship to Patient*
Guarantor's Phone Number
Please enter a valid phone number.
Guarantor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guarantor's Date of Birth*

MonthDayYear
Date
Guarantor's Social Security Number*

Insurance

I hereby authorize to my insurance company release of all information necessary for the payment of benefits. I hereby assign payment of benefits by my insurance company to VWFP.
Primary Insurance Company*
Primary Insurance Policy Address (Submit Claims to)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Policy ID #*
Primary Insurance Policy Group #*
Primary Insurance Policy Phone Number
Please enter a valid phone number.
Primary Insurance Subscriber Full Name*

First NameLast Name
Primary Insurance Subscriber Date of Birth*

MonthDayYear
Date
Primary Insurance Subscriber Gender*

MaleFemale
Primary Insurance Subscriber Social Security Number*
Relationship to Patient*
Do you have another insurance?

YesNo

Secondary Insurance Company
Secondary Insurance Policy Address (Submit Claims to)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Policy ID #
Secondary Insurance Policy Group #
Secondary Insurance Policy Phone Number
Please enter a valid phone number.
Secondary Insurance Subscriber Full Name

First NameLast Name
Secondary Insurance Subscriber Date of Birth

MonthDayYear
Date
Secondary Insurance Subscriber Gender

MaleFemale
Secondary Insurance Subscriber Social Security Number
Relationship to Patient
Do you have another insurance?

YesNo

Tertiary Insurance Company
Tertiary Insurance Policy Address (Submit Claims to)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tertiary Insurance Policy ID #
Tertiary Insurance Policy Group #
Tertiary Insurance Policy Phone Number
Please enter a valid phone number.
Tertiary Insurance Subscriber Full Name

First NameLast Name
Tertiary Insurance Subscriber Date of Birth

MonthDayYear
Date
Tertiary Insurance Subscriber Gender

MaleFemale
Tertiary Insurance Subscriber Social Security Number
Relationship to Patient

VWFP Patient Financial Policy

Thank you for choosing Van Wert Family Physicians as your primary care provider. We are committed to providing you with quality health care. Your clear udnerstanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any quesitons about our fees, our policies, or your responsibilities. It your responsibility to notify our office if any patient information changes (i.e., names, address, telephone, insurance information, etc).

Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at the time of service. If you are insured by a plan we do business with, but don't have an up-to-date insurance card, payment in full for each visit is required if we can't verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments and deductibles. All co-payments, deductibles and any balance due, must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment and/or deductible at each visit. If your deductible has not been met, we will collect a fee of $100 at your visit. To make payments convenient, we accept all major credit cards, money orders, cash and checks. Multiple online payment options and Care Credit are available as well. The charge for a returned check is $30 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.

Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

Proof of insurance. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to bill your insurance. This can be done prior to your visit by responding to a pre-visit check in text you will receive. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request.

Nonpayment. It is our office policy that all past due accounts be sent 2 statement of balances over $5.00. If payment is not made on the account, phone calls and letter wil be sent to try to make payment arrangements. If no resolution can be made, the account will be sent to the collection agency and possible discharge from the practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis.

Self-Pay Accounts. Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which thes office does not participate, or patient without an insurance card on file with us are considered self pay. We do not accept attorney letters or contingency payments. It is always the patient's responsibility to know if our office is participating with their plan. if there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven. Please ask to speak with the Billing department to discuss a mutaully agreeable payment plan.

Finance charge. You will be assessed a finance charge at the rate of 18.5% every month, on unpaid patient balances over 30 days old.

Minors. The parent(s) or guardian(s) is responsible for full payment and will receive the billing statements. A signed release to treat may be required for unaccompanie minors.

Van Wert Family Physicians' Financial Policy Patient Signature

Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Your signature indicates that you have read and understand our financial policy and agree to abide by it.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Initials Acknowledging that you have Read Policy
Todays Date*

MonthDayYear
Date

Van Wert Family Physicians

Consent to Treat

I First Name* Last Name* (patient name) give permission for Van Wert Family Physicians to give me medical treatment.

I allow Van Wert Family Physicians to file for insurance benefits to pay for the care I receive.
I understand that :
- Van Wert Family Physicians will have to send my medical record information to my insurance company.
- I must pay my share of the costs.
- I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
I understand:
- I have the right to refuse any procedure or treatment.
- I have the right to discuss all medical treatments with my clinician.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Initials Acknowledging that you have Read Policy
Todays Date*

MonthDayYear
Date

Van Wert Family Physicians

HIPAA PHI Discolsure Form

I direct my health care and medical services' providers to disclose and release my protected health information to the following individuals. This includes all my personal health information, unless otherwise noted.

This authorization will remain in effect until I notify Van Wert Family Physicians that an update is required due to a change in the above information.
Please list the name, relationship and contact number for all persons you want to have listed on your HIPAA. I.E John Smith (father) 419-xxx-xxxx*
Name of Individual giving Authorization*

First NameLast Name
Todays Date*

MonthDayYear
Date

VWFP No Show and Late Cancellation Policy

Effective - April 1, 2023

We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and mid-level providers. That's why it is very important that you keep your scheduled appointment with us and arrive on time.

As a courtesy, and to help patients remember their scheduled appointments, Van Wert Family Physicians sends a text reminder 4 days and 2 days in advance of the appointment time or a phone call the day before the appointment time.

If your schedule changes and you cannot keep your appointment, please contact us so we may reschedule you, and accommodate those patients who are waiting for an appointment. As a courtesy to our office as well as to those patient who are waiting to schedule with the physician, please give us at least 24 hours notice. You may call our office at 419-238-6251 and press 0 for scheduling to cancel your appointment. You may also leave a voicemail after office hours by calling 419-238-6251 and choosing Option 5.

If you do not cancel or reschedule your appointment with at least 24 hours notice, we may assess a $25 no show service charge to your account for medical services and $75 for mental health services. This no show charge is not reimbursable by your insurance company. you will be billed directly for it. If you arrive more than 10 minutes after your scheduled appointment time, you may be asked to reschedule your appointment.

After three no-shows within a 12 month period, our practice may decide to terminate its relationship with you.

I understand the no show and late cancellation policy of Van Wert Family Physicians and understand that I may be charged a fee for any no-show of a scheduled appointment. I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order to avoid a potential no show charge.
Patient Name*

First NameLast Name
Patient Initials Acknowledging that you have Read Policy
Date*

MonthDayYear
Date
Should be Empty:

Patient Registration

Guarantor

Insurance