Welcome to Magnolia Primary Care LLC

New Patient Registration is completed in 2 steps:

Step 1 (This Form): Demographics, insurance, and practice policies.
Step 2 (Separate Form Sent via Text): Medical history and appointment scheduling.

Patient Name: {patientName}; DOB: {Demoinfo}

Patient Name: {patientName}; DOB: {Demoinfo}

Business Hours
Monday, Tuesday, Thursday 8.00am - 4.00pm
Wednesday, Friday 8.00am - noon
Lunch break (all days) 12.00pm - 12:30pm
Closed on weekends, holidays. For more information visit: www.magnolia.clinic

Thank you for choosing Magnolia Primary Care LLC! To ensure you receive the best possible care, please review our office policies. Contact us with any questions.

 

If your insurance changes: Before switching plans, please verify that your new insurance is on our approved list. If you switch to a plan that is not on our list or is an affiliate of an accepted plan:

• We will be unable to bill the insurance on your behalf.
• You will be responsible for payment at the time of service based on our Self-Pay Fee Schedule.

We recommend contacting our billing office or your insurance provider directly if you are unsure of your plan’s status.

Arrival & Check-In Policy
Your appointment time is reserved exclusively for you. To ensure we provide the highest quality care and stay on schedule for all patients, please adhere to the following arrival guidelines:

The "5-Minute" Completion Rule - All check-in processes, paperwork and necessary intake steps must be fully completed no later than 5 minutes after your scheduled appointment time.

Late Arrivals & Fees If the above process is not completed on time due to your late arrival, we will be unable to see you and will need to reschedule your visit. A $40 late arrival fee will apply to your account.

• Standard Appointments: Please arrive 15 minutes early.
• Medicare Annual Wellness Visits: Please arrive 30 minutes early to also allow for comprehensive intake process 

We appreciate your cooperation in helping us provide the attention and care every patient deserves.

Understanding Your Bill: How We Code Your Visits
We want to be transparent about how your visit is billed to your insurance. Here's a breakdown of the factors involved:

• Type of visit: Are you here for a routine check-up, a sick visit, or a follow-up appointment? Each type of visit has a different billing code.
• Time spent with the care team: This includes the time you spend with the physician, as well as any time spent with our nurses or medical assistants.
• Documentation: Accurately documenting your visit takes time, and this is factored into the billing code.
• Complexity of your visit: We consider the complexity of your health concerns, which may include reviewing your medical history, ordering and interpreting tests, and coordinating care with other providers.

It's important to understand that the complexity of your visit is a key factor in determining the billing code, even if it doesn't directly relate to the time spent during your appointment.

Because of these factors, your visit may be billed using more than one code to accurately reflect the services you received.

We are committed to providing you with the best possible care, and that includes clear and honest communication about billing. If you have any questions about how your visit is billed, please don't hesitate to ask.

​Communication & Correspondence Policy

Phone Communication

• Designated Lines: Please use our two monitored lines only: 256-203-6676 or 256-203-3949.
• Voicemail Requirement: We do not return calls based on "missed call" logs. You must leave a voice message to receive a callback.
• Response Times:
  
  • Medical Questions or Scheduling: Responded to by the end of the next business day.
  • Billing Inquiries: Responded to within three (3) business days.

Patient Portal (Non-Urgent Needs Only)
For non-urgent requests, we encourage the use of our Patient Portal.

• Response Time: Messages will receive a reply within 24 hours (excluding weekends and holidays).

Asynchronous Digital Communication Fees
Medical care provided outside of a face-to-face visit requires physician time and expertise. Asynchronous communication (digital evaluation that does not happen in real-time) includes portal messages, telephone consultations, and non-face-to-face digital services.

• Billing: We will bill your insurance for these services if your plan provides coverage.
• Self-Pay: If your insurance does not cover digital communication, a $15.00 fee will be applied per communication.

Note: This does not apply to "Telehealth" visits, which are billed as standard appointments.

After-Hours & Weekend Care
Urgent Concerns
We offer Telehealth services for urgent concerns that occur after hours or on weekends.

• These visits are billed to your insurance as a Telehealth visit. Coverage is determined by your specific insurance policy.
• If your concern is not urgent and can wait until the next business day, please call us during regular hours.

Emergencies
If you suspect you are experiencing a medical emergency, do not wait for a callback.

Call 911 immediately or proceed to the nearest Emergency Room..  

No-Show & Cancellation Policy
Cancellations & Rescheduling

• Late Cancellation Fee: Any cancellation made less than 24 hours before your scheduled time will result in a $40 fee.
• Advance Notice: We appreciate a courtesy notice of at least 48 hours for any rescheduling requests.
• Frequency Limits: To ensure the consistency and effectiveness of your treatment plan, regular visits are essential. Multiple scheduling disruptions (3 consecutive or 4 total within a calendar year) compromise our ability to provide high-quality care and may result in discharge from the practice.

No-Show Policy - A “No-Show” occurs when a patient misses an appointment without any prior notification.

• Administrative Fee: Each "No-Show" incident will result in a $50 fee.
  Two "No-Shows" within 1 Year: This will result in a temporary suspension of services.
• Reinstatement Process: If your services are suspended, you will receive a formal letter. To remain a patient at this practice, you must schedule a meeting with your Primary Care Physician within 30 days of that letter to evaluate the circumstances.
• Prescription Grace Period: We will provide 30 days of essential prescription refills during this window. If you do not meet with your physician within those 30 days, your status with our practice will be permanently terminated.

Payment & Insurance Responsibilities
Insured Patients: Your Coverage & Responsibilities
Your insurance policy is a contract between you and your insurance provider. While we submit claims to your primary, secondary, and/or tertiary plans as a courtesy, you are ultimately responsible for the following:

• Information Updates: Please notify us of insurance changes immediately. Failure to do so may result in you being responsible for the full claim balance.
• HMO/Managed Care Requirements: If your plan requires you to select a Primary Care Provider (PCP), you must do this before your visit. We cannot do this for you. If a PCP is not assigned to our office prior to the appointment, your insurance will likely deny the claim, and you will be responsible for the full cost.
• Knowing Your Benefits: It is your responsibility to understand your deductibles, co-pays, and coverage limitations.
• At Check-In: All co-pays and outstanding balances must be paid before you are seen by the provider.

Preventative Care vs. Medical Concerns
During a "Preventative Care Visit" (Physical or Annual Wellness Visit), our primary focus is screening and prevention.

• If we address new acute issues or chronic medical conditions during that same visit, we may be required to submit a separate claim for those services.
• These additional services may be subject to co-pays and deductibles according to your plan’s rules.

Account Management & Delinquent Balances
We strive to keep you informed of your account status via monthly letters and emails.

• 120 Days Past Due: If a balance remains unpaid after 120 days (and after three reminders), we will reach out via phone or text for a final resolution or to set up a payment plan.
• Consequences: If no proactive measures are taken to settle the balance by the provided date, you will be discharged from the practice and the account will be turned over to a collection agency.

Uninsured (Self-Pay) Patients
Payment is required at the time of service:

• Base Visit Fee: $200 for a 30-minute visit (collected at check-in).
• Additional Services: Fees for injections, vaccinations, ear lavage, EKGs, etc., will be collected at check-out.

Non-Covered Administrative Fees
Insurance does not cover administrative costs. These will be billed directly to you:

• No-show fees / Late cancellation fees / Late arrival fees
• Form completion fees.
• Asynchronous communication charges.
• Medical records requests.

Controlled Substances

We do not regularly provide chronic pain management services with controlled substances or narcotics. Any chronic pain needs or other medical conditions requiring long-term controlled substances treatment will be referred to providers who can better manage your healthcare needs. 

​Medications & Prescription Refills

• All prescription refills require a 48 - 72 hour notice to our staff to process and this may be longer if your insurance company requires a Prior Authorization. Holidays and weekends may also delay these requests. 
• If you call to request a refill but are overdue for a follow-up visit and/or blood work (necessary for monitoring the safety or effectiveness of a medication), the provider may agree to call in enough medication to the pharmacy to last until we are able to schedule an office visit. This is in your best interest and to ensure that you are responding adequately to a medication and to ensure adequate safety and side effect monitoring.
• Patients are requested to bring all medication bottles currently being taken, including over the counter medication to each visit.
• We will not be able to call in new prescriptions without being seen in office.
• If you need a change in existing prescription because you are having problems with side effects, or need a change in dosage, please schedule an appointment to discuss problems to explore alternative options

Referrals and Authorizations

• Please allow 7-14 business days for referrals/prior authorizations to be worked on. Most plans do not allow retro-referrals. Please ensure that your referral is active before seeing a specialist.
• If your insurance plan requires renewal of referral each year, you are responsible for letting us know of this in advance and we will help you with this, but we cannot initiate or renew referrals until we get a request from you to do so. 

Test Results 

• It may take up to 7 business days for your lab or imaging results to be reviewed, processed and communicated to you. Our staff will make every effort to notify you of these results as soon as they are processed and reviewed by the provider. Some labs (i.e. Lyme testing, stool samples, cultures) and imaging (MRI’s and CT Scans) may take much longer to process.
• Any lab/imaging result will be published to the portal once we have made attempts to discuss it with you over phone/ during a visit. You can avail these by logging into the portal.
• Some results will require an appointment with your Provider to review and you may be asked to schedule a visit to discuss these with the provider.
• We only contact patients with results for testing we have ordered. If your testing was ordered by another provider outside of Magnolia Primary Care LLC, please contact the ordering provider for results.

Patient Portal
We strongly urge our patients to register to the patient portal (no cost for this service) in congruence with the Terms and Conditions set forth in the patient portal agreement. Please note that you can avail your visit notes, instructions, lab/test results, send messages to the clinic staff and pay bills via the portal. We do charge for any asynchronous portal communication that requires physician time.

Forms
We understand that health forms are required by many schools, employers, and government agencies. Please note that a fee of $20 per single-sided page is charged each time we complete a form, as this requires our time and effort. Some forms may require an office visit with one of our providers for completion in which case you will be asked to come in for a visit. 

Medical Records Policy
Our practice utilizes a fully digital Electronic Health Record (EHR) system. Your health information is available to you through several different channels depending on your needs.

Accessing Your Records

• Provider-to-Provider: We do not charge for faxing records directly to another healthcare provider for your ongoing care.
  Patient Portal (Free): You may access, view, and download your records at any time through the Patient Portal at no cost.
• Personal Copies: If you require personal copies outside of the portal, a signed medical release form is required.
  • Printed Copies: $0.50 per page plus mailing charges.
  • USB/Pen Drive: $25 per drive plus mailing charges.

Processing Timeline - By law, medical offices are allowed 30 days to complete records requests. While we strive to fulfill requests as quickly as possible, please allow for this window when making your request.

Account Inactivation & Portal Access
If you choose to leave the practice or are formally discharged, your account will be inactivated 30 days following the formal notification.

**Important: Due to EHR configurations, portal access is automatically disabled once an account is inactivated.

You can opt for the provider- to - provider fax options, the personal copy option OR to ensure you maintain access to your health history, we also recommend one of the following options:

• Option A: Immediate Download (Highly Recommended) Log into your portal before the 30-day inactivation date to download and save your records to your personal device at no cost.
• Option B: "Non-Patient" Portal Access If you wish to maintain portal access after leaving the practice, we can transition your account to "Non-Patient" status. This allows you to view your history but removes you from our active clinical schedule.

Action Required: You must notify us by the date specified in your notification letter to set this up. You will be required to establish a new password for this account.

Inclement Weather
In the case of extreme weather we must close the office so it does not compromise the safety of our staff & patients. In such instances, we utilize patient approved communication methods to send automated notifications by text/e-mail/portal messages/voice calls. 

Patient Dismissal
We work hard to give you the best care possible. While we make every effort to work with you we reserve the right to dismiss any patient from our practice. In case of dismissal, you will be notified by certified mail of this non-negotiable decision. You will have 30 days to find another provider during which we will continue to offer urgent care services and refill appropriate medications. Common reasons for dismissal include: Failure to keep appointments; significant non-compliance with prescribed treatment plan; abusiveness to staff; failure to pay your bill etc. 

Patient Name: {patientName}; DOB: {Demoinfo}

Consent for Treatment

I, {patientName} {Demoinfo}, am voluntarily seeking healthcare and hereby consent to medical treatment, procedures, laboratory tests and other health care services. I understand that I have the right to refuse specific treatments or procedures. However, by signing below, I agree in general, to permit laboratory and diagnostic tests, routine medical treatment (for example, medications, injections, drawing blood for tests, counseling, screening tests, health education and other diagnostic procedures), emergency procedures as necessary, and hospital services performed at the request of the attending physician or other physicians assisting in my care. The consent given shall be valid and binding and the physician(s) can rely on this authorization and accept any consent given by the patient until such time as physician receives written notice that the authorization is revoked.

Patient Name: {patientName}; DOB: {Demoinfo}

Patient Name: {patientName}; DOB: {Demoinfo}

Responsibility for Payment

Assignment of Benefits & Release of Information

I request that payment of authorized Medicare, commercial, and other private health insurance benefits be made directly to Magnolia Primary Care LLC for any services or supplies furnished to me. I authorize Magnolia Primary Care LLC to release to the Centers for Medicare & Medicaid Services (CMS), its agents, commercial insurance carriers, or third-party payers any medical information necessary to determine benefits or process claims for services provided.

Financial Responsibility

I understand that I am fully responsible for all fees due to Magnolia Primary Care LLC as a result of services I have received and that all fees are due and payable at the time of service unless Magnolia Primary Care LLC agrees to accept assignment of my insurance benefits.

I understand that assigning benefits to Magnolia Primary Care LLC and the filing of an insurance claim on my behalf does not absolve me of my responsibility to pay for services if my primary and supplemental insurance policies fail to pay for these services or if deductibles and/or co – pays are due. I understand that my insurance policy may not cover the full cost of services, or may not have coverage benefits for these services. I therefore agree to be responsible for those charges incurred, as well as for my co-pay and/or any deductible that has not been met.

I further understand that any verification of my insurance benefits by the Clinic is not a guarantee of payment by my insurance company. If my insurance company does not pay for the services I have received, I understand that the Clinic will bill me for these services and I agree to pay any amounts due within 90 days of receipt of a bill for these services.

A copy of this authorization may be used in place of an original and this authorization shall remain in force until revoked by me in writing.

Patient Name: {patientName}; DOB: {Demoinfo}

Patient Name: {patientName}; DOB: {Demoinfo}

At a Glance
This notice describes how Magnolia Primary Care LLC handles your medical information, outlines your privacy rights regarding your health records, and explains our legal duties to protect your personal health data.

Notice of Privacy Practices 

Effective January 1, 2026

This notice details our responsibilities, your rights and how we may use or disclose your health information

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. You may also revoke such a written consent any time by submitting a request to revoke consent. 

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will post a copy of the revised notice on our website www.magnolia.clinic.  We will also post a copy at our office. The notice will also be available upon request. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.

Use and Disclosure

• We disclose health information about you when state or federal laws require it, including reporting to the Department of Health and Human Services to demonstrate compliance with federal privacy regulations.
• We provide your health information to you or your designated personal health representative to facilitate your privacy rights described in this notice.
• We share health information to bill and collect payment from health plans or other paying entities. Example: We send health data to your health insurer to obtain reimbursement for services.
• We share information to coordinate your medical treatment with other treating healthcare professionals. Example: A doctor treating your injury consults another specialist regarding your medical history.
• We use and share health information to operate our practice, improve patient care, and contact you directly (e.g., appointment reminders).
• We disclose health information whenever mandatory legal obligations require us to do so.
• We disclose health information to respond to lawsuits, court orders, subpoenas, or administrative proceedings.
• We disclose health information to public health authorities and the FDA to address public safety, prevent disease, assist with product recalls, and report medication reactions.
• We report information to government or protective agencies when investigating suspected abuse, neglect, or domestic violence.
• We disclose limited health information to law enforcement to prevent or lessen serious threats to health or safety, report crimes, or locate missing persons.
• We can disclose health information about you with organ/tissue procurement organizations.
• We share information with coroners, medical examiners, or funeral directors following an individual's death.
• We share health information to comply with workers' compensation laws.
• We disclose information for health research when protocols satisfy federal privacy standards.
• We may disclose your health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased.
  In these cases we never disclose your information unless you give us written permission - Marketing purposes, Sale of your information, Most sharing of psychotherapy notes

Your Rights

• You have the right to obtain a copy of your medical record and other health information we have about you or for it to be sent to a third party by written request for this. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• You have the right to ask us to amend your medical and billing records if you believe it is incorrect or incomplete. Your request must be in writing and provide the reasons for the requested amendment. If we deny your request, we will inform you within 60 days and you may have a statement of your disagreement added to your health information.
• You have the right to ask to restrict uses or disclosures of certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you have the right to ask us not to disclose that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information and provided such a request is submitted in a timely manner
• You have the right to ask for lists (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, health care operations, provided to correctional institutions or law enforcement officials and those for which federal law does not require us to provide an accounting. We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months
• You have the right to choose someone to act for you including as medical power of attorney or your legal guardian. That person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
• You have the right to request confidential communications and specify the way you would like to be contacted including phone number, email or to send mail to a different address. You will be requested to fill in a form for the same and if you ever want to change this, you will need to change that information in writing as well.
• You have the right to ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Your Choices

For certain health information, you can tell us your choices about what we share. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious or incapacitated, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Contact and Complaints

If you have questions about your rights, please contact your provider at (256) 203 6676.

Submit written requests to exercise your rights (including modifying confidential communications, requesting record amendments, or obtaining copies of medical records) to:

Please note: Standard email is not secure. Please do not include sensitive health information in your emails.

*You have the right to file a complaint if you feel your rights are violated.  You may file a complaint with us to the above address or you may notify the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not take any action against you for filing a complaint. 

 

Patient Name: {patientName}; DOB: {Demoinfo}