New Patient Intake Form

Protecting your privacy is taken very seriously at this office.  We do not share any of your information with anyone who is not directly involved in caring for you.

Unless you have expressly authorized someone on this form, no information will be shared with any person other than the patient. 
This office conforms to strict HIPPA rules regarding any patient information.  HIPPA privacy laws explains how medical information will be used and disclosed.  HIPAA privacy rules give individuals the right to request a restriction on uses and disclosures of their protected health information (PHI).  The individual is also provided the right to request confidential communications or that a communication of the PHI be made by alternative means.

Some of the ways used to protect your information:

-  Only people that need the information to care for you have access to that information.

-  Access to computer system is limited and password protected.

-  A physical firewall is employed to prevent hacking.

-  P4 level secure shredding to shred any documents with your information on it.

-  Only what you authorize to be released with the person named below will be shared, nothing else.

Controlled substances such as medications for pain, anxiety or insomnia are controlled by the DEA. The goals of prescribing these medications is to help patients improve their ability to work and to function at home. However, these are dangerous medications that have very serious side effects that include accidental overdose and death. Addiction to these medications is a serious national problem leading to thousands of accidental overdoses and deaths annually. This agreement maybe renewed every year.

By signing, I have been informed of the following: that while taking prescribed medications

1. If I drink alcohol or use street drugs, I may not be able to think clearly, and could become sleepy, risking injury or death.

2. I may get addicted to these medicines.

3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.

4. If I need to stop this medicine, I must do it slowly or I may get very sick.

By signing, I agree to the following:

1. I am responsible for my medications. I will not share, sell or trade my medications. I will not take anyone else’s medications

2. I will NOT increase my medicine until I speak with my doctor.

3. My medications may not be replaced if it is lost, stolen, or used up sooner than prescribed.

4. I will keep all appointments set up by my doctor. (Missed appointments are a breach of this contract)

5. I will bring the pill bottles with any remaining pills of these medicines to each clinic visit (if requested).

6. I agree to give a blood, urine, or saliva sample to comply with national drug safety guidelines.

1. Schedule II controlled medications (pain meds, ADHD meds) require monthly visits (in person or video)

2. Refills will only be done during regular office hours—Monday through Friday.

3. No refills on nights, holidays, or weekends. It may take up to (3) working days to refill medicines.

4. Patient is responsible to keep track of their medications.

5. No early or emergency refills may be made except in rare circumstances.

As a general rule, it is best to not fill prescriptions from other providers. It creates the impression that you are attempting to get more medication than you should. If you do need to get medication from other providers, you must inform the office.

If I break any of the rules, or if my doctor decides that this medicine is hurting me more than helping me, this medicine may be stopped by my doctor and NO FURTHER PRESCRIPTIONS FOR CONTROLLED SUBSTANCES WILL BE FILLED.

We regularly perform urine drug screening to ensure compliance with DEA rules. We are required by law to check CURES (has info on all controlled substances you have filled). I agree to provide primary care for you even if you are no longer getting controlled medicines from me. - This agreement will be scanned into the patient’schart.

We are dedicated to providing you with the best possible medical care. As part of that dedication, we want to make sure that your experience with the billing department is as hassle free as possible.

1) New Patient Visits are NOT going to be billed as annual wellness visits (annual physicals).  

2) Annual Wellness Visits (AWV) (annual physical), includes preventative care we provide such as dietary and exercise habits, review of vaccines, discussion of screening tests, lifestyle behaviors, etc.

3) Insurance (Medicare) has specific criteria that they are willing to pay for as part of your AWV. A general review of your medical conditions can be part of the AWV. However other items that are addressed outside of the normal AWV can incur a regular office visit because insurance will not cover those items and you may be charged a copay if you have one.

4) Copays are not an extra amount above the allowed insurance amount. Total payment is determined by CMS and then insurance subtracts copays from that total payment and pays the difference.

5) The amount billed by our office is not very relevant, insurance pays the same amount irrespective of how much is billed.

6) Not all insurances cover all services, and it is nearly impossible for us to know all covered items prior to services rendered. If your insurance plan determines a service to be “not covered”, you may be responsible for payment

7) Patients with multiple chronic medical conditions might be enrolled in the chronic care management program. This is simply an extra tool to helps us better care for patients and insurance re-imburses the office for such service. If requested, we can provide you with documentation regarding this to explain it further.

8) There is a website created by the government so people can find information regarding financial relationship between the pharmaceutical industry and medical providers. That website is (openpaymentsdata.cms.gov (Legal requirement to let patients know about this law)

We understand that unplanned issues can come up and you may need to cancel an appointment. If you are unable to keep your appointment, please kindly call our office 48 hours in advance. Appointments are in high demand and early cancellation will give another person access to that appointment time.

If you cancel late (less than 48 business hours) or do not show up for your appointment, the following applies:

Showing up 10 minutes past your appointment time is considered a no show.

1) For regular office visits (15-minute appointments): You will be charged a $150.00 fee.

2) For AWV/Physical/New Patient Visit/Hospital Follow ups (30-minute Appointments) No show or late cancellation, you will be charged a $300.00 fee

 

Medication Refills require 24 to 48 hours to get it filled. We make every attempt to get it filled same day.

I have read and understand the financial policy of Meena Medical Group. I agree to be bound by its terms. I also understand and agree that such terms maybe amended by the practice from time to time.