Please read the below Patient Expectations and Responsibilities, and click you have read and I agree to the terms. 

Patient Expectations:

1.       Have the expectation to be treated in a manner reflecting respect for their privacy and dignity as a person.

2.       Have the expectation to be informed regarding their diagnosis, course of treatment and prognosis in terms they can reasonably be expected to understand and to participate in decision making about their health.

3.       Have the expectation to receive sufficient information to enable them to give informed consent prior to the initiation of any procedure and/or treatment.

4.       Have the expectation to discuss their medical record with the physician and to receive, upon written request, a copy of that record.

5.       Have the right to expect information pertaining to their health care will be treated as confidential and will not be released without their, or their authorized representative’s written permission, except as required by law.

6.       Have the expectation to be informed of unforeseen delays in the provider’s schedule.

7.       Have the expectation to be able to make a complaint and to receive response to that complaint within a reasonable period of time.

 

Patient Responsibilities:

1.       Have the responsibility to be considerate and cooperative in dealing with office staff and providers.

2.       Have the responsibility to follow instructions and guidelines given by those providing health care services and to weigh potential consequences of any refusal to comply with those instructions or recommendations.

3.       Have the responsibility to obtain and carefully consider all information needed or desired in order to give informed consent for a procedure or treatment.

4.       Have the responsibility to assist in compiling a complete medical record by providing or authorizing release of medical information from other providers.

5.       Have the responsibility to notify their primary care physician (PCP) prior to seeking consultation or emergency services, except in potentially life threatening situations.

6.       Have the responsibility to schedule appointments and to arrive on time for scheduled visits or to notify their physicians’ offices if they must cancel or be late for a scheduled appointment.

7.       Have the responsibility to express opinions, concerns or complaints in a constructive manner.

 

LABWORK

Throughout the course of your care, MASRI MEDICAL may send blood and tissue samples to a variety of clinical laboratories. If you insurance plan contains restrictions or limitations on lab work, please make that known to our staff before your blood is drawn or sent for processing. Provided you let us know in advance of a test being performed, we can in many instances route routine samples to labs that will accept your insurance. There may be some specialty tests required that only a limited number of reference labs are capable of performing. In those instances patients will be responsible for the fees incurred at those labs if their insurance does not participate with them.

Please be aware that MASRI MEDICAL has no role in or control over billing issues related to clinical laboratory fees. If you have questions about bills received for laboratory charges or insurance coverage available to you, please contact the clinical laboratory in question and / or your insurance carrier. We regret that our billing staff can provide only minimal assistance to you in mitigating laboratory charge issues.

Please read the below Patient Financial Agreement, and sign you have read agree to the terms.

Patient Financial Agreement

Welcome to MASRI MEDICAL. Please read carefully this important information about your responsibility for payment for your care and services.

The providers of MASRI MEDICAL are participating providers with most insurance companies. However, our list of accepted insurances is subject to change at any time and not all plans under all companies are accepted. To avoid unexpected charges, please confirm that your particular health benefit plan is accepted by MASRI MEDICAL. You should contact your insurance carrier before making an appointment to familiarize yourself with the limits of your policy and what it will and will not provide coverage for. We do our best to guide patients through this process, but ultimately it is impossible for us to keep abreast of the requirements in the thousands of insurance products on the market. It is an individual patient responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.

Please be aware that, except as contractually agreed otherwise by MASRI MEDICAL, patients are ultimately responsible for insuring payment for all medical services provided. If a carrier denies payment for services because a plan requirement was not met, services were considered “non-covered”, the plan benefits were exceeded, care is considered medically unnecessary, or treatment is considered experimental, among other reasons, patients will be held accountable for those charges.

Although MASRI MEDICAL will generally submit a claim to insurance for our patients, if your insurance requires you to pay a co-payment and or deductible, you will be required to pay that portion of the cost at the time of service. We will ask you for payment at the time of check in and registration at the front desk. If you do not pay your co-payment at the time of service, we will bill you for the co-pay, along with an additional $35 fee to offset the cost of billing.

Please bring your insurance card with you each visit and notify our staff of any changes in your coverage. All patient accounts are to be paid at the time of service. We will ask you for payment on any outstanding balances. MASRI MEDICAL accepts cash, checks and major credit cards. Checks that are returned to MASRI MEDICAL unpaid from your account will be assessed an additional $50 NSF fee.

Please read the below HIPPA Authorization, and sign you have read agree to the terms.

Patient Financial Agreement

Welcome to MASRI MEDICAL. Please read carefully this important information about your responsibility for payment for your care and services.

The providers of MASRI MEDICAL are participating providers with most insurance companies. However, our list of accepted insurances is subject to change at any time and not all plans under all companies are accepted. To avoid unexpected charges, please confirm that your particular health benefit plan is accepted by MASRI MEDICAL. You should contact your insurance carrier before making an appointment to familiarize yourself with the limits of your policy and what it will and will not provide coverage for. We do our best to guide patients through this process, but ultimately it is impossible for us to keep abreast of the requirements in the thousands of insurance products on the market. It is an individual patient responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.

Please be aware that, except as contractually agreed otherwise by MASRI MEDICAL, patients are ultimately responsible for insuring payment for all medical services provided. If a carrier denies payment for services because a plan requirement was not met, services were considered “non-covered”, the plan benefits were exceeded, care is considered medically unnecessary, or treatment is considered experimental, among other reasons, patients will be held accountable for those charges.

Although MASRI MEDICAL will generally submit a claim to insurance for our patients, if your insurance requires you to pay a co-payment and or deductible, you will be required to pay that portion of the cost at the time of service. We will ask you for payment at the time of check in and registration at the front desk. If you do not pay your co-payment at the time of service, we will bill you for the co-pay, along with an additional $35 fee to offset the cost of billing.

Please bring your insurance card with you each visit and notify our staff of any changes in your coverage. All patient accounts are to be paid at the time of service. We will ask you for payment on any outstanding balances. MASRI MEDICAL accepts cash, checks and major credit cards. Checks that are returned to MASRI MEDICAL unpaid from your account will be assessed an additional $50 NSF fee.

(If applicable) Parent or Legally Authorized Representative In case the subject is beyond the legal age of consent: