Patient Information

To better facilitate your care, we kindly ask for contact information for anyone involved in your support system, such as family members, friends, or caregivers who may assist with scheduling or driving you to appointments. This helps us keep everyone informed and ensures your appointments run smoothly. Thank you!

 **Please present all insurance and information to the receptionist for registration. I hereby authorize Premier Vascular, LLC (DBA: Premier Vascular) to provide any necessary medical or other information about me or my dependent to my insurance company, and/ or its designated representatives, for the purpose of attaining payment. This authorization is valid as long as I am a patient of Premier Vascular. I hereby assign to the provider all payments for healthcare services, including behavioral and mental health treatment, rendered to myself or my dependent.

I understand that my insurance company may only cover a portion of my total bill, or may cover nothing at all. I understand I am responsible for all bills related to the provision of healthcare services and will be responsible for payment of any charges not covered under this assignment. If for any reason my or my dependent’s account becomes delinquent, I agree to pay for any and all charges related to re-billing, cost of collections, reasonable legal fees, and any other charges permitted by law.

I hereby request that payment of authorized Medicare benefits be made on my behalf to Premier Vascular or any healthcare services provided to me or my dependent. I authorize Premier Vascular to provide any necessary medical or other information about me or my dependent to the Health Care Financing Administration and its agents as needed to determine these benefits or the benefits payable for related services.

I request that payment of authorized Medigap benefits be made to Premier Vascular for any healthcare services provided to me or my dependent by Premier Vascular. I hereby authorize Premier Vascular to provide any necessary medical or other information about me or my dependent to the Medigap carrier as needed to determine these benefits or the benefits payable for related services.

Your protected health information will be used by Premier Vascular. It will be disclosed to others solely for the purposes of treatment, obtaining payment or supporting the day-to-day health care operations of the practice.

I hereby authorize for Premier Vascular to receive and release any medical records for my proper health care treatment. I give Premier Vascular permission to request, receive, and share my medical records as needed for my care and treatment. I understand that I have the right to look at and get a copy of any information shared under this authorization. I also understand that I do not have to sign this form in order to receive treatment. I may cancel this authorization at any time by putting it in writing, but any information already shared before that point cannot be taken back. I also understand that once my information is shared, it may be re-disclosed by the recipient and may no longer be protected by law. By signing below, I agree to the use and sharing of my health information as described above.

PAYMENT POLICY
Payment of Insurance and/or Medicare Benefits to: Premier Vascular, 1902 Forysth St, Macon, GA 31201

I request payments be made directly to the provider listed on the claim for services furnished to me during the effective period of this authorization. I authorize the above listed provider(s) to release to the Social Security Administration, its intermediaries or carriers any information required for any claim to be paid and processed. I authorize the release of any information necessary to determine these benefits or the benefits payable for related services.

CANCELLATION & NO-SHOW POLICY
If you are unable to keep your appointment, you are obligated to inform our office within 24 business hours of your scheduled office visit or ultrasound appointment and 48 business hours for an in-office surgery or hospital surgery. If you do not cancel your appointment within that time frame, you will be classified as a “no-show” and subject to a non-cancellation fee as follows: Office visits $35.00, Ultrasounds $50.00, In-office surgery $150.00 and Hospital surgery $200.00. Three appointment “no-shows” will result in being discharged from our practice. Your signature below acknowledges that you have read and understand our non-cancellation policy.

Acknowledgement: I understand I am ultimately responsible for payment for the services I receive at Premier Vascular, regardless of my health insurance coverage, I understand Premier Vascular will not act as an administrator to resolve my personal financial agreements regarding my medical care. I have had the opportunity to read this Patient Financial Responsibility Agreement in its entirety and have had the opportunity to ask questions regarding the details of this Agreement. Any questions have been answered to my satisfaction. I consent and agree to the aforementioned policies of Premier Vascular and understand they may be changed without notice. Co-pays and outstanding patient balances are due at times of service. Failure to pay will result in patient not being seen.

 The patient or authorized representative recognizes the need for care and consents to ANY and ALL medically necessary services as ordered by the physician and at the discretion of the patient. These services may include lab procedures, medical treatment, minor or emergency surgical treatment, exam or other services rendered under the specific instructions of the physician.

Premier Vascular, LLC is committed to providing high-quality care. As part of your treatment, we may use photography, video, or audio recordings (“multimedia imaging”) to help with diagnosis, treatment, and professional education.

These images are used only for medical purposes and will be stored securely in compliance with Premier Vascular policies, as well as state and federal laws. Images may include certain body parts to show their condition at a specific point in time. They will not include features that identify you. Multimedia images may be shared only for your medical care, billing, or other healthcare operations. Any other use will require your written permission.

I have read and understand this policy regarding the use of photography, video, or audio recordings as part of my treatment at Premier Vascular, LLC. I have had the opportunity to ask questions, and my questions have been answered. By signing below, I give permission for multimedia imaging to be used as described above.

I have been made aware of Premier Vascular, LLC “Notice of Privacy Practices” (“Notice”). I received a copy of this document on today’s date, and I have a right to request additional copies in the future. The Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills, or in the performance of Premier Vascular, LLC healthcare operations. The Notice also describes my rights and responsibilities with respect to my protected health information.

I understand that copies of the Notice are available in the registration areas of each facility and on Premier Vascular, LLC system website at www.premiervascularsurgery.com. I understand that I may request a copy of the Notice at any time. Premier Vascular, LLC reserves the right to change the privacy practices that are described in the Notice at any time and will make a revised Notice available for review. I may obtain a revised Notice of Privacy Practices by requesting a copy or by accessing Premier Vascular, LLC website listed above.

Transportation providers must remain on-site with the patient at all times and depart the office no later than 4:30 p.m.

If transportation leaves before the patient is discharged, the driver must complete a signed acknowledgment accepting full responsibility for returning to pick up the patient.