Premier Internal Medicine of Alpharetta, PC FINANCIAL POLICY
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1 Premier Internal Medicine of Alpharetta, PC FINANCIAL POLICY Thank you for choosing Premier Internal Medicine of Alpharetta, PC for your health care needs. We are committed to building a successful physician-patient relationship with you. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. name, address, insurance information, etc). Co-pays The patient is required to present a current insurance card and picture ID at each visit. If you do not provide proof of insurance, you will be responsible for the claim. All co-payments and past due balances are due at time of checkin. We accept cash, debit and credit cards. We do not accept checks. Insurance Claims Insurance is a contract between you and your insurance company. Understanding your insurance benefits is your responsibility. Therefore, please be sure that you verify that our physician is in your network, what your out-ofnetwork benefits are, and what your insurance covers. If you have questions about your coverage, please contact your insurance company with any questions before your appointment. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately. If your insurance plan is one with which we are not a participating provider, you will be responsible for payment in full. However, as a courtesy, we will file your initial insurance claim and if not paid within 30 days you will be responsible. Referrals and Preauthorizations
2 Certain health insurances (HMO, POS, etc.) require that you obtain a referral or prior authorization from you Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility. Alternative payment arrangements or rescheduling of your appointment may be necessary if not obtained. Self-pay Accounts Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. It is always the patient s responsibility to know if our office is participating with their plan. If there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven. Self-pay patients are required to submit full payment at the time of service. Please ask to speak with a billing coordinator to discuss a mutually agreeable payment plan. It is never our intention to cause hardship to our patients, only to provide them with the best care possible and the least amount of stress. Missed Appointments Premier Internal Medicine of Alpharetta, PC requires 24-hour notice of appointment cancellation. Appointments missed that are not previously canceled may be charged a fee of $ Medical Record Copies Patients requesting copies of medical records will be charged: $15 under 10 pages $25 under 20 pages $35 21 to 49 pages $50 over 50 pages Outstanding Balance Policy It is our office policy that all past due accounts be sent two statements. If payment is not made on the account, a single phone call will be made to try to make payment arrangements. If no resolution can be made, the account will be sent to the collection agency, and may result in discharge from the practice. In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs, including attorney fees and court costs. Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any
3 other personal party. This financial policy helps the office provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to contact us. PREMIER INTERNAL MEDICINE OF ALPHARETTA, PC RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THE INFORMATION AT ANY TIME. AUTHORIZATION FOR TREATMENT AND ASSIGNMENT OF BENEFITS I have the legal authority to authorize the examination and treatment of the undersigned by Premier Internal Medicine of Alpharetta, PC and its staff. I authorize all insurance benefits be paid directly to Premier Internal Medicine of Alpharetta, PC. RELEASE OF BILLING INFORMATION I authorize Premier Internal Medicine, PC to bill my health insurance company for services provided to the named individual listed on this form. I agree and acknowledge that my signature on this document authorizes Premier Internal Medicine of Alpharetta, PC to submit claims for services rendered without obtaining my signature of each claim to be submitted for myself and/or dependents and that I will be bound by this signature as though the undersigned had personally signed the particular claim. RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a copy of Notice of Privacy Practices from Premier Internal Medicine of Alpharetta, PC. AUTHORIZATION TO VIEW EXTERNAL PRESCRIPTION HISTORY I authorize Premier Internal Medicine of Alpharetta, PC to view my prescription history from external sources.
4 Premier Internal Medicine of Alpharetta, PC OFFICE POLICY Thank you for choosing Premier Internal Medicine of Alpharetta, PC for your health care needs. In order to make your transition to our practice as seamless as possible, please review and sign to following office polities. Please feel free to seek clarification at any time regarding any of our policies. Patient Identification All patients must complete our New Patient Packet prior to seeing the doctor. We must obtain a copy of a valid government issued picture ID and current valid insurance card. Without of the proper ID, you may not be seen. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Cell Phones We ask that you do not use cell phones in our clinical areas. Referrals & Prior Authorizations Please allow 5-7 business days for referrals/authorizations to be approved. When providing information to us to initiate a referral, please provide the provider s name, address, phone number and date of appointment. It is your responsibility to ensure a referral is active BEFORE being seeing by a specialist. Medications and Prescriptions Refills Please bring ALL medication bottles currently being taken, including over the counter medication, with you to each office visit. All prescription refills require hours notice to our staff to process. Please call to request refills or utilize the patient portal. Please note that if you call to request a refill and are overdue for a follow-up visit and/or blood work, the physician may agree to call in enough medication until you are able to schedule an office visit (2 weeks maximum). If is your responsibility to schedule an appointment before you run out of medication. You should always schedule your next visit before you leave our office. We do not call in new prescriptions without being seen in the office. This includes antibiotics. If you are having side effects or need a change in the dosage of your medication, please call the office to schedule an appointment to discuss with the physician in detail and to explore alternative options. Prior authorizations for medications are done as a courtesy. After Hours and Emergency Care Please call after hours for non-life threatening matters that can not wait until normal business hours. Please call 911 or report to the nearest ED immediately for life-threatening or urgent medical concerns. Messages We encourage our patients to contact us through the patient portal for general questions and/or concerns. Our goal is to respond the same day. Non-urgent messages will be returned within 48 hours. Cancellations & Missed Appointments Appointment times are an important commitment of reserved time for you and the physician and practice. Missed appointments create an interruption for the staff and other patients on the schedule.
5 It is your responsibility to confirm your appointment with our office or if needed kindly cancel your appointment within 24 hours. No Show Policy No Show is defined as when a patient has a scheduled appointment and does not show up as scheduled and without cancellation notification to the office. o New Patients: 1 st No Show Office will notify patient by phone and remind patient of no show policy. 2 nd No Show Office will notify patient by mailing a final letter indicating termination of services (Appointment will not be rescheduled.) o Established Patients: 1 st No Show Office will notify patient by phone and remind patient of no show policy. 2 nd No Show Office will notify patient by letter detailing no show policy. 3 rd No Show Office will notify patient by mailing a final letter indicating termination of services. Termination of services will include a grace period of 30 days for prescription refills. It will be the patient s responsibility to find a new primary care physician and contact his/her insurance carrier for assistance with finding another physician. o All No Show Occurrences are subject to a $25.00 fee. Late for Appointment Forms Please kindly give us a call if you are running behind for your appointment. If you are more than 15 minutes late when arriving for your scheduled appointment, you may be asked to reschedule. A $25 form fee will be charged for all forms completed. Please note that some forms require a face to face visit to be completed. Please note that we do not complete Social Security disability forms. Patient Dismissal We reserve the right to terminate the patient relationship based on medical non-adherence, threatening or abuse behavior, failure to keep scheduled appointments, and failure to pay as described in our financial policy. I acknowledge that I have read and understand the office policy for Premier Internal Medicine of Alpharetta, PC and agree to abide by its guidelines.
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Authorization to Release Health Information
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Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth
Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
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Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name)
Patient Name Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name) Date of Birth: / / Age: Sex/Gender: Address: / / / (Street/PO Box) (City) (State) (Zip Code) Phone
GASTROENTEROLOGY CONSULTANTS, P.C. M. Thomas Riddick, M.D. Melvin Bullock, M.D.
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Today s Date (mm/dd/yyyy):
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PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
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Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
PHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
Patient Registration. Patient Information. Guarantor Information (skip if same as patient) Emergency Contact Information. Insurance Information
Patient Registration Patient Information Patient name (Last, First) Patient date of birth Patient gender (M / F) Patient marital status Mailing address (address number & street) Patient Social Security