New Patient Intake Forms

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other commercial insurance company, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

Your clear understanding of our office policies is important to our professional
relationship. Please ask the office staff if you have any questions about our policies, fees, or your responsibilities. Please review this carefully and sign to confirm your understanding.

Office Hours and Contact Information

Our office is open Monday through Thursday 8:30am to 4:00pm, with some Friday hours by appointment only. We can be reached by telephone at (316) 858-1351, and our fax number is (866) 303-9647. You may email the office at  ello@healthystrategies.org, but please do not use email for urgent needs or emergencies. Please allow one business day for response to messages or emails.

Prescription refills should be requested from your pharmacy, who will contact us directly if you have no refills remaining or the prescription is expired.

For urgent after-hours medical needs, not including prescription refills, you may page the on-call provider by calling (316) 858-1351 and selecting option 8. You will be prompted to leave a detailed message, which will be sent directly to the provider, who will return your call.

Appointments

Please arrive five to ten minutes early for your appointment to complete forms and update information. If you are more than five minutes late, you may be asked to reschedule.

Please bring a current list of the medications you are taking, or your medications in their pharmacy & over-the-counter bottles to each appointment. It is important for you to know which medications you are taking, and for us to ensure that your chart is up to date.

Cancellations and “No-shows”

Please provide at least 24 hours’ notice when cancelling or rescheduling an appointment. Failure to provide proper notice when cancelling/rescheduling an appointment or “no- showing” will result in a $50.00 fee. Reminder calls/texts/emails are a courtesy we provide, but it is ultimately your responsibility to keep and be on time for scheduled appointments. We understand that there may be extenuating circumstances or unforeseen events and can make exceptions in certain cases, but please contact us as soon as possible.

Insurance

Healthy Strategies Family Doc, PA currently participates with most health insurance plans. It is the patient’s responsibility to provide the office with current insurance information. We ask that you bring your current insurance card(s) to every appointment so that we will be able to determine coverage and your financial responsibility. If current insurance information is not available at the time of service, you will be considered self-pay and will be required to pay for services at the time of the visit. If you are unable to pay at the time of service, your appointment will be rescheduled.

Your insurance policy is a contract between you and your insurance company. We will file your insurance claims as a courtesy to you, but will not become involved in disputes between you and your insurance company. We will, however, supply documentation as necessary. Ultimately, you are responsible for timely payment of your account.

Copays and Patient Out-of-Pocket

Your copay is due at the time of service. We accept payment via cash, check, money order, Visa, MasterCard, Discover, and American Express. Returned checks will be subject to a $45.00 fee payable by cash, money order, or credit/debit card.

If you have a deductible plan and your deductible is unmet, you will be required to make a payment of $100 at the time of service, and we request that you put a payment card on file. Once your insurance company processes your claim, any outstanding balance will be sent to you via mail. You may call our billing office at (316) 858-1351 ext. 3 to set up payment arrangements if you are unable to pay in full. However, you will be asked for payment at subsequent appointments. Any outstanding balances over 90 days will be considered for further collection activity.

Referrals

Some insurance plans require referrals for patients to see specialists or have tests outside of their Primary Care Provider’s office (PCP). The insured/patient is responsible for making sure that referrals are completed by the PCP’s office and sent to the outside facility before services are rendered. Without referrals, outside facilities/providers will ask for payment in advance of service. Referrals cannot be backdated or made retroactively.

Lab & Pathology

We use LabCorp and Quest Diagnostics for laboratory testing. We use Kansas Pathology Consultants (KPC) and Quest Diagnostics for our pathology services. It is the patient’s responsibility to know if your insurance contracts with these facilities. If they do not, please notify the staff prior to your visit so we can send your specimens and/or orders to the correct facility. All labs do their own billing, so you will receive separate statements for their services. If you have questions about those bills, please refer to the phone number on their statement.

Misc. Forms and Mailings

There is a fee of $25.00 for any forms completed by Dr. your provider outside of an
appointment – this includes FMLA paperwork. This does not apply to forms requested by a patient’s insurance carrier.

There is a fee of $1.00 for any copies, forms, or prescriptions that a patient would like
mailed to them. To avoid this fee, patients can request to pick these up from the office at any time during office hours. These fees are not billable to your insurance company and will be due upon receipt.

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the
appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.
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I voluntarily request a provider physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of
1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
• Obtaining payment from third party payers (e.g. my insurance company)
• Other disclosures as allowed or required by law.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices [linked below], which contains a more complete description of the uses and disclosures of myprotected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

You may change or revoke these permissions at any time.