FORMS
Family History Questionnaire
Congeriem posset: glomeravit sorbentur cetera nulli. Nullo nullo ripis caecoque cinxit
Patient Authorization
Effigiem iapeto habentem videre vindice? Iudicis principio semine levius nebulas
Medical History
Regna astra quin regio ipsa perpetuum aequalis. Fixo umentia supplex duas vis nondum chaos
Financial Agreement
Agitabilis abscidit parte aliud agitabilis persidaque freta sanctius formaeque.
POLICIES
New patient asked to arrive 15 minutes early to complete paper work. You can download, print and complete the forms prior to your appointment. Please bring the completed forms, a list of all medications you currently taking, your insurance card and identification (ID) card to your appointment.
| New patient:
|
|
|
To better serve the needs of all our patients, we ask that you call at least 24 hours in advance to cancel or reschedule appointments. We make every effort to stay on schedule, although emergencies arise. Cancel/reschedule 3 times continuously, your care will be terminated by our office.
|
We require payment of your co-payment and past due account balances at the time of service. We accept cash, debit and all major credit cards (Visa, master Card, Discover, and American Express).
You are responsible for paying all co-pays at the time of service. Insurance companies stipulate that we cannot waive co-pays, co-insurance, deductibles or payments for non-covered services. Any outstanding balance will also be requested when you check in for your visit.
| We accept most of commercial health insurance, marketplace insurance, Medicaid and Medicare. Please call to the location you wish to make an appointment with to verify.
Insurance information will be updated annually. Please present your insurance and a photo ID (Driver's License) is required at your first visit and a picture maybe taken for your medical record. We will submit claims to most major insurance carriers. Please bring your insurance card and I.D. with you to every visit so we can ensure that our records are accurate.
We recommend that you call your insurance company to verify that we participate with your plan.
Please notify us if you have any change in your name, phone number, address, or insurance as soon as it occurs.
If our office is unable to verify your insurance eligibility, you will be required to pay for your office visit at that time.
It is your responsibility to know the details of your insurance coverage and to notify us of any changes to your policy.
|
Patients should first contact the pharmacy for refills of prescriptions taken on a regular basis. The pharmacy will either fill the prescription or contact our office to request an authorization. If our office has not seen you within the past three months, you may be asked to schedule an appointment in order to obtain a medication refill. Similarly, prescription refills for medications that you do not take regularly or have been prescribed by another doctor typically require an office visit. To prescribe or refill an antibiotic, an in-person evaluation is necessary. Our policy is to not prescribe new medications over the telephone, unless discussed at a prior office visit. Otherwise, for medical legal reasons, we are required to evaluate you prior to writing a new prescription.
A medical release waiver must be signed in order to obtain a copy of your medical records or to have them sent to another health care provider. If you are requesting that your records be sent to another provider we ask that you supply us with their name, address, phone number and fax number.
We will provide to you, upon written request, an electronic or paper copy of your medical records. There will be a $7 fee charge to provide the record to you, your insurance company, or another provider to whom we have not referred you for treatment.
Please call after hours only for urgent matters. In case of a life-threatening emergency, you should always call 911 or go to the nearest emergency room.
If you need after hour advice for medical concern, please call 281-477-0417 and our answering service will assist you.