PATIENT INFORMATION

ATTORNEY INFO (ONLY COMPLETE IF YOUR VISIT IS DUE TO AN AUTO ACCIDENT/SLIP AND FALL)

PLEASE READ AND SIGN

I request that payment of authorized health plan benefits be made on my behalf to Pohlman Pain Associates LLC for any services furnished by that physician/facility/supplier. I authorize any holder of medical information about me to release to HCFA and its agents any information needed to determine these benefits payable to any related services. I understand that my signature requests that payment be made and authorized release of medical information necessary to pay any claim. If other health insurance is indicated in item 9of HCFA 1500 form or elsewhere on the approved claim form or electronically submitted claims, my signature authorizes release of information to the insurer or agency shown. Any unpaid balance that is forwarded to a collection agency, I understand that I would be responsible for any collection fees.

I understand that under the health insurance Portability & Accountability Act of 1996 (HIPPA), I have the right to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and followup among multiple healthcare providers who
  may be involved in my treatment directly and indirectly.
• Obtain payment from third party payers. (e.g., Medical Insurance)
• Conduct normal healthcare operations such as quality assessment and physician certification.

I have reviewed and read your notice of Privacy practices. If I choose to, a complete copy of the Privacy Policy is available for me to keep. I understand that Pohlman Pain Associates LLC has the right to change its Notice of Privacy Practices from time to time, and I may review it any time. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations

You are responsible for your insurance policy.

Due to the many changes in insurance policies, we cannot be responsible for interpreting each individual policy. It is your responsibility to know your coverage and its limitations, as well as who is a provider on your plan. We advise you to check with your insurance company regarding your benefits package. Failure to comply could result in you, the patient, being responsible for all costs incurred. Remember that your insurance policy is a contract between you and your insurance company. It is your responsibility to know or find out, whether we are providers for your specific network.

This policy has been established to help us serve you better. It is necessary for us to make appointments to see our patients as efficiently as possible. When an appointment is made, it takes an available time slot away from another patient.No-shows and late-cancellations delay the delivery of healthcare to other patients, some who are quite ill. A “no-show” is missing a scheduled appointment.

We understand that situations such as medical, family or work emergencies occasionally arise. These situations will be considered on a case-by-case basis. Please understand that insurance companies consider this charge to be entirely the patient’s responsibility.

OFFICE VISITS: A CHARGE OF $25.00 WILL BE ASSESSED FOR EACH NO-SHOW.
PROCEDURES: (OUTPATIENT AND IN-OFFICE) A CHARGE OF $100.00 WILL BE ASSESSED
FOR EACH NO-SHOW OR LATE CANCELLATION (WITHIN 48 HOURS).

FYI…

Referrals: If you are required to obtain a referral from your insurance company or from your primary physician to be seen in this office, the referral must be present at the time of your visit. If it is not available, it will be your responsibility to obtain a referral. You will need to reschedule your appointment should a referral not be available. We request you call your primary care physician and have your referral faxed to us. Our fax number is (754) 229 - 3866. 

Nonparticipating Provider Policy: If we are not a provider for your insurance company, we will collect the fee in full at the time of service. 

Your Financial Responsibility: you are responsible for payment of any copayments, coinsurance, deductibles, and non-covered services at the time of service. Because we are specialist, some diagnostic invasive procedures are not considered part of your office visit co-payment and may be applied to your deductible and/or coinsurance.

Please call your insurance company and learn coverage. It may save you a lot of confusion and expense.

Pohlman Pain Associates understands that your pain is a significant hindrance to the quality of life you desire. To help you achieve your goals we may utilize oral narcotics or other medications supplemented with the procedures you receive here. Narcotics have a long history of safety when used in the proper manner. Side effects can include, but not limited to, constipation, urinary retention, itching, nausea, and sometimes confusion. Addiction to narcotics may occur with use over several weeks; therefore, we must weigh the risks versus benefits before using these medications. We will discuss these with you when they are prescribed, and your pharmacist will also give you more information. It is important to take all medications in the way that they are prescribed by your PPA physician. Taking more medication than is prescribed for you can result in, but not limited to, respiratory failure, cardiac arrhythmias. GI bleed and/or death. Please be certain to take your medications as prescribed. Listed below are the conditions you must adhere to be under the care of the PPA. If any of these rules are broken, we reserve the right to dismiss you from our care.

NEW PATIENT CONSULTATION

The undersigned insured person ( or guardian of such person) affirms:

1. The services or treatment set forth below were actually rendered. This means that those services have already been provided.
2. I have the right and the duty to confirm that the services have already been provided.
3. I was not solicited by any person to seek any services from the medical provider of the services described above.
4. The medical provider has explained the services to me for which payment is being claimed.
5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

1. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.
2. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
3. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.
4. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627. 732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Assignment to Release Information

You are authorized to release any information you deem appropriate concerning and physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by as a result of professional services rendered by you, and I hereby release you of any consequence thereof.

Assignment of Cause of Action

In the event any insurance company is obligated by contractual agreement to make payment to me or you for the demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is/are believed to be correctly set forth under pertinent date below) and authorize you to compromise, settle or otherwise resolve said claim as you see fit. I understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due), I personally owe you, and I agree to pay you in a current manner.

Protection of Outstanding Charges. If the above named client recovers money damages from any person or entity responsible for charges incurred by the above named , we agree to withhold from the net proceeds of any check or draft in which we are an additional named payee, sufficient funds, after deduction of attorney's fees and costs, to pay any outstanding medical bills in our possession for any and all undisputed charges owed to you in connection with the accident or event giving rise to and covered by the recovery and not covered by any collateral source.

Amount Protected. It is the health provider's obligation to furnish us with periodic updates of outstanding charges. Otherwise, we will rely on previously received records in seeking reimbursement from the tortfeasor. Under no circumstances will we withhold a sum larger than that submitted to the tortfeasor for reimbursement.

Balance Confirmation. We will use best efforts to request a balance confirmation when recovery is imminent. If we fail to receive a written response within five (5) days of mailing we will presume that the balance has been paid in full.

Pro Rata Distribution If Inadequate Recovery. If the net recovery is less than the total outstanding charges owed to all health providers covered by a letter of protection or any other lien holder, such funds will be distributed on a pro rata basis.

Our Responsibility on Forensic Services. This law firm acknowledges independent responsibility to the health provider for charges incurred for medical records and witness fees. 

Disputes. If our client disputes any of your outstanding charges or claims a setoff and we are unable to resolve the issue, we will deposit the amount of the disputed charge/setoff into the court registry for judicial determination.

Approval Require. This agreement becomes effective when you and the client approve it in writing in the place provided below and return it to our office.