New Life Full Patient Information Form

New Life Full Patient Update Form

New Life Center for Bariatric Surgery is a division of Premier Surgical Associates.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.

Insurance Information

Participating Insurance Companies: For those companies we participate with, Premier Surgical will file your claim for you and accept assignment for payment directly to us. Please provide us with current and valid insurance cards.

Non-Participating Insurance Companies: In those cases where we are non-par, Premier will file your insurance claim for you but will not accept assignment, meaning payment will be made directly to you. You are responsible for payment of your account in full so please plan to direct any payments to us.

Referrals and Authorizations: It is your responsibility to understand your benefit design and obtain all required referrals and authorization approvals from your insurance company. Failure to do so will result in reduced benefits and higher patient responsibility for you.

Other Payment Information

Office Visits: All co-pays, deductibles or co-insurance are due at the time of service.

Surgery: If surgery is required, you will be responsible for all or a portion of the fee, payable in the form of a deposit at the time of scheduling. If you are having non-urgent or elective surgery, 100% of the estimated patient responsibility portion will be due prior to scheduling the service. If you have a life threatening illness and need urgent or emergency care, we will not delay your surgery; however, non-urgent or elective surgeries may be delayed pending payment of your portion of the estimated fees. If you do not have insurance and need to discuss a payment plan, please notify us before we schedule your surgery.

Work's Compensation: You must contact your employer and their worker's compensation insurance company and be assigned a case worker before we will be able to treat you for a worker's compensation injury. Payment Options / Billing Questions - Payment options include cash, check, MasterCard, and Visa. For billing questions or credit care payments, you may reach us at 865-306-5700. Payments may be mailed to Premier Surgical Associates, PO BOX 52948, Knoxville, TN 37950-2948

Interest and Fees: Balances not paid in full within 30 days are subject to interest at 18% APR. Balances that are turned over to collection agencies are assessed a 30% collection fee.

Returned Checks: If your check is returned for non-sufficient funds, you expressly authorize your account to be electronically debited or bank drafted for the amount of the check plus any applicable fees. The use of a check for payment if your acknowledgement and acceptance of this policy and its terms and conditions. A $25.00 charge will be added to your account for each returned check. Additionally, you will not be able to schedule any follow-up appointments until the fee is paid in full.

Patient's Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Missed Appointment Fees: In order to provide the best care and service to our patients, we ask that you notify us 24 hours in advance to cancel and/or reschedule your office visit, ultrasound or other diagnostic test appointment. A minimum of 30 and up to 90 minutes is set aside for each appointment and your communication and compliance is much appreciated by your physician and supporting staff.

Please be aware that if 24 hour notice is not received a fee of $25 may be charged to your account which must be settled before another appointment is scheduled.

Please call us if you are unable to keep your scheduled appointment. This will provide us an opportunity to reschedule your appointment to a more convenient time and avoid any additional charges on your account.

Self-Pay Accounts:For patients who have no insurance plan, payment is expected at the time of service for all services including surgeries. If a procedure or surgery is scheduled, a deposit of at least $150 will re required at the time of scheduling. If you need to make payment arrangements please contact us at 865-306-5700.

Collection Accounts:A collection fee of 30%will be added to all accounts that are turned over to collection agencies.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGED

I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information (Notice).

FINANCIAL RESPONSIBILITY

I understand and commit to the following:

1. I have received a copy of Premier's financial policies and have read and understand these policies.

2. I will pay my co-pay, deductible and co-insurance at the time of service.

3. I will provide the most current insurance information and immediately notify Premier of changes.

4. If surgery is required, all or a portion of my financial responsibility must be paid prior to surgery.

5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances.

6. I understand that I am responsible for all balances.

7. If I have no insurance, I have informed Premier and I am responsible for 100% of all balances.

8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.

INSURANCE AUTHORIZATION AND RELEASE

I request that payment of authorized benefits - including Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC, for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC, to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from mu insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC, any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Patients Signature*

Clear
Date*

MonthDayYear
Date

Worker's Compensation or Auto Insurance Information
Your Supervisor
Supervisor's Phone No.
Format: (000) 000-0000.
Workers Compensation or Auto Insurance Phone No.
Format: (000) 000-0000.
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adjuster's Name
Adjuster's Phone No.
Format: (000) 000-0000.
Claim Number
Approval Number
Date of Injury

MonthDayYear
Date
YesNo
YesNo
Briefly describe injury or accident:
For Medicare Supplement Policies Only

One-Time Medigap Assignment and Release
Name

First NameLast Name
Medicare Number
Medigap Policy Name
Medigap Policy Number
I request that payment of the authorized Medigap benefits be made on my behalf to Premier Surgical Associates, PLLC for services furnished to me by them. I authorize any holder of medical information about me to release it to:
Name of Policy
Any information needed to determine these benefits or the benefits payable for related services. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Patient's Signature

Clear
Date

MonthDayYear
Date

PATIENT MEDICAL RECORD RELEASE AUTHORIZATION
Date*

MonthDayYear
Date
Patient Date of Birth*

MonthDayYear
Date
Patient Name*

First NameLast Name

I hereby authorize the release of my personal health information to the following relatives or individuals:

Rows	Name	Relationship
1
2
3
4
5
6

For the purpose of you treatment and our payment and operations we will disclose your protected health information to physicians, other medical professionals, hospitals and insurance companies, Otherwise it is our policy to release such information only to the patient unless otherwise specified to do so by you in writing. This authorization will not expire unless revoked by you by giving us written notice of such revocation. Information disclosed under this authorization may be disclosed again by the person or organization to which it is given and is no longer protected by federal privacy regulations.

I hereby authorized New Life Bariatric/Premier Surgical to release my protected health information to the individuals listed.
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Life Full Patient Update Form

Patient Information Form

Medical Records Release

Emergency Contact Information

Pharmacy

Consents

Phone Messages

Insurance Information

Worker's Compensation or Auto Insurance Information

For Medicare Supplement Policies Only

PATIENT MEDICAL RECORD RELEASE AUTHORIZATION