New Patient Registration Form

I have received, read and understand the Notice of Privacy Practices document of the complete description of the uses and disclosures of my health information. I understand that FirstCare Medical has the right to change its Privacy Practices from time to time and that I may contact this organization at any time for a current copy of the Notice of Privacy Practices document.

Welcome to FirstCare and thank you for allowing us the opportunity to participate in your care. We have streamlined our billing process to reduce expenses and allow us to deliver quality care to all, including those without insurance.

Cancellation & No Show: Each time a patient misses an appointment by cancelling less than 24 hours in advance or no showing, it prevents us the opportunity to offer another patient an appointment to see one of our providers. Therefore, FirstCare Family Practice and FirstCare Medical charges fees as follows:
• 1st No show or less than 24-hour cancellation = Warning, no fee
• 2nd No show or less than 24-hour cancellation = $50 no show fee
• 3rd No show or less than 24-hour cancellation = $100 no show fee
• 4th No show or less than 24-hour cancellation = Discharged from the practice.
These Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. We do understand that certain circumstances are unavoidable and may cause you to cancel within 24 hours. Fees in this instance may be waived, but only at the discretion of management. Our practices firmly believe that a good practice/patient relationship is based upon understanding and good communication.

Self-Pay Patients: Payment for services can be paid in cash, check or credit card (MC, VISA or DISCOVER) and must be paid at the time of service. We do not accept American Express.

Insured Patients: Insurance is a contract between you and your insurance company. We are not a party to this contract. We will bill your insurance company, and it is the insurance company that makes the final determination of your eligibility. You are personally responsible for any balance that your insurance company does not cover. If your insurance company requires a referral and/or pre-authorization, you are responsible for obtaining it. Failure to obtain referral and/or pre-authorization may result in a lower payment or a claim denial from your insurance company. If we are not a provider under your insurance plan, you will be responsible for payment in full at the time of service. As a courtesy we will file your initial insurance claim and if not paid within 45 days, you will be responsible for the total bill.

*** Any co-payments required by yourinsurance must be paid at the time of service. ***

• When your insurance company reimburses us for your visit, your responsible balance will be billed to you.
• If payment is not received before the next billing cycle (30 days), a $20.00 late fee will be added to the next bill and each billing cycle until full balance paid. The balance is then sent to a Collection agency and you and your
immediate family will not be able to receive services at FirstCare until that balance is settled.
• In addition, a $30.00 administrative fee and any applicable interest and/or collection fees will be added to the balance and must be paid before being seen again.
• There is $25.00 fee for any returned checks by the bank for any reason.
• If you are delinquent on your account on more than one occasion, we reserve the right to collect payment in full in advance, of $140 at the time of service. We will then submit the claim to your insurance company and reimburse you accordingly after the claim is paid.
• Payments can be made online at https://www.firstcaremedcenter.com/

Worker’s Compensation (Urgent Care only):Our staff will schedule your appointment after your worker’s compensation carrier calls in advance to verify the accident date, claim number, primary care physician, employer information, and referral procedures. Worker’s Compensation (Out of State) and Occupational Injury, payment in full is requested at the time of service. It is the patient’s responsibility to provide our office staff with employer authorization and contact information regarding a worker’s compensation claim. If the claim is denied by the workers compensation insurance carrier, it then becomes the patient’s responsibility.

Waiver Confidentiality: You understand that if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received services at our facility may become a matter of public record.

Medical offices often incur significant expenses trying to collect payment for services rendered. This is one of the reasons medical care can be so expensive in our country. We appreciate your understanding.

It is your responsibility to notify this office in a timely manner when your refill is due. We respectfully ask that you notify us 7 days in advance of your medication running out, as approval of your refill may take up to 7 days and allow appropriate time for a provider to review your chart. 

Do not wait until your medication has run out, as we do not guarantee same day refills. 

When calling for your medication refill, please provide the name(s) of the medication your are requesting a refill on, the dose, how many days you have left, and which pharmacy you would like your refill sent to. 

FirstCare Family Practce does not accept automatic prescription refill requests from your pharmacy. It is the responsibility of the patient to contact this office for their medication refill.

Medication refills will only be addressed during regular business hours (Monday - Friday, 8am - 4:30pm). FirstCare Family Practice is closed on Saturday and Sundays and most holidays. 

It is important to keep your scheduled appointment to ensure that you receive your medication refill on time.  Repeated no shows, reschedules, or cancellations will result in a denial of refills and require a visit with one of our providers to receive your medication refill. All prescriptions require a follow up appointment at least every 3-6 months or at the provider's discretion. 

If a patient runs out of medication and our office does not have any available appointments, they can be seen at our Urgent Care, at which time no more than a 30 days supply will be prescribed.  Patients on long term narcotics/controlled substances must be seen in person by a provider at the Urgent Care, and may receive a prescription for an appropriate  amount of days worth of medication until the next available appointment as the provider's discretion. 

 Office Hours:

FirstCare Family Practice is open from 8:00 am - 4:30pm, Monday - Friday.
FirstCare Walk-In Urgent Care is open from 8:00 am - 7:00pm Monday - Friday and 10:00 am - 4:00 pm  on Saturday and Sunday. I acknowledge that there are no providers avaiable after hours and if it is an emergency, I should go to my closest emergency room or call 911. 

Hosptials:

FirstCare Family Practice provides out-patient medical services. We do not admit to hospitals. Any patient of the FirstCare Family Practice that needs to be admitted will be admitted through the hospitalist services at Mid-Hudson Regional Hospital or Vassar Brothers, but I acknowledge that any emergency department would be acceptable.

Appointments:

I acknowledge that if I arrive later than 15 minutes past my scheduled appointment it may result in needing to be rescheduled. FirstCare will be unable to maintain a practice / patient relationship with patients who have multiple late arrivals and no shows. 

Telephone Calls & Messages:

I acknowledge that phone calls and voicemails left with our office will be returned within 2 business days. Please leave only one message and include your name, date of birth, phone number and reson for calling.