2216 Newport Blvd. Costa Mesa, CA Phone: Fax:
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1 Hours 8 a.m.- 5 p.m. Mon Thurs, 8 a.m.- 4 p.m. Friday Closed 12:30 p.m. - 2 p.m. for lunch, Closed for all major holidays Contact Information 2216 Newport Blvd. Costa Mesa, CA Phone: Fax: Ample free parking located on the side/back of the building accessible from Virginia Place and Newport Blvd (one way street traveling north). After Hours Please call for physician on-call. After Office Hours For urgent medical issues after regular office hours that cannot wait until next business day, please call our office number to be connected to the on-call doctor s paging service. For all other issues, please call us during our regular office hours. Same Day/ Urgent Appointments We understand that sometimes medical problems come up and you would like to be evaluated sooner than the next available appointment. Please let us know and we will try to accommodate you the same or following day. Emergencies Call for medical emergencies Medication Refills We do not want you to run out of your medications. We recommend that you notify the pharmacist to send us a refill request when you are picking up your last refill. If you prefer to call us, please call us during our regular office hours and allow 3-4 business days for us to refill your medications. Page 1 of 7
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3 Medical Spa Services Questionnaire (please check all that apply) Eyelash lengthening, fullness, thickness, or darkness Skin Care Products/Consult Blocky Skin Weightloss (diet/medication) Acne Treatment Facial Veins or Redness Age Spots Chiropractic Laser Skin Resurfacing Personal Training-strength training Acupuncture BOTOX Cosmetics-finelines Facial Folds Thin Lips Facial Fullness Cellulite Treatment Microdermabrasion Page 3 of 7
4 No Show Policy 1) If there is need to reschedule or cancel your appointment, we ask that you notify us at least 24 hours in advance. 2) We have reserved this appointment time for you on the doctor s schedule in order to handle your medical needs in an efficient and timely manner. If notice of rescheduling or cancellation is within 24 hours of the appointment reserved for you, there will be a $50 charge. 3) Accumulation of 3 missed appointments may result in a notice of non-compliance and denial of rescheduling. Canceling Appointments 1) As of January 2009, we will require 24 hours notice or 1 business day s notice, whichever is greater to cancel an appointment. Failure to provide this notice will result in a service charge of $50.00, which will NOT be covered by your insurance company. 2) We ask that one be respectful of our time and of other patients who are trying to get an appointment by adhering to this cancelation policy. Forms Please make an appointment if you have any forms that will require our doctors to fill out. Most forms require an Evaluation and possible laboratory testing to complete. If forms are walked in without an appointment the charge will be $35.00, DMV physicals with required forms at time of the visit will be $125.00, and Sports/School physicals will require a waiver signed if no insurance coverage the charge will be $75.00 Page 4 of 7
5 Practice Insurance and Billing Policies 1) All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. 2) Once the insurance company is billed we allow 60 days for the balance to be paid by your insurance carrier. If the insurance carrier does not remit payment in 60 days, the balance will be due in full from you. If any payment is subsequently made by your insurance carrier in excess of the balance, we will gladly refund the overpayment to you within 30 days, providing that you do not have any outstanding accounts with our office. It is also customary to pay for professional services when rendered unless prior arrangements are made. I request that payment of authorized Medicare/other insurance company benefits be made on my behalf to Newport Medical and Wellness Regulations pertaining to Medicare assignment of benefits apply. 3) The patient authorizes any holder of medical or other information about me to release to the social security administration and healthcare financing administration or its intermediaries or carriers, any information needed for this or a related Medicare claim or other insurance claim. They permit a copy of this authorization to be used in place of the original and request that payment of medical insurance benefits be made payable to Newport Medical and Wellness. A patient understand that it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment.(section 1128b of the social security act and 31 u.s.c provides penalties for withholding this information.) 4) There is a $25.00 charge for all returned checks. All unpaid balances may be subject to 1.5% interest or minimum $6.00 service charge after 90 days. If your account must be forwarded to a collection service and/or an attorney because of nonpayment, you will be responsible for all collection fees and/or attorney fees charged by these services. 5) NO SHOW POLICY-If there is need to reschedule or cancel your appointment, we ask that you notify us at least 24 hours in advance. 6) We have reserved this appointment time for you on the doctor s schedule in order to handle your medical needs in an efficient and timely manner. If notice of rescheduling or cancellation is within 24 hours of the appointment reserved for you, there will be a $50 charge. Accumulation of 3 missed appointments may result in a notice of non-compliance and denial of rescheduling. 7) APPOINTMENT CANCELATION As of January 2009, we will require 24 hours notice or 1 business day s notice, whichever is greater to cancel an appointment. Failure to provide this notice will result in a service charge of $50.00, which will NOT be covered by your insurance company. Page 5 of 7
6 Patient Responsibilities As a partner in your healthcare, you have the following responsibilities: 1) I will provide accurate health information to your doctor and update us with any health changes. 2) I will schedule routine physical exams and other health maintenance exams recommended to me by my doctor (Pap smear, mammogram, bone density, colonoscopy, routine blood tests, immunizations, etc.). I put myself at risk for not detecting other medical diseases if I only see my doctor for immediate problems. I will make appointments with my doctor to discuss routine health screenings. 3) I will follow treatment plans recommended to me by my physician, including completing testing, making an appointment with a specialist, and taking my medications. I will be sure to clearly comprehend any treatment plan and ask questions when I do not understand. I understand that not following my treatment plans may put my health at risk 4) I will keep my appointments and reschedule any missed appointments. I understand that my doctor schedules these appointments to follow up on my response to treatment and to monitor my medical conditions. During these appointments my physician may order tests, refer me to a specialist, change my medications, and diagnose a medical problem. If I do not follow up, I may put my health at risk and may have medical conditions go undetected. 5) I understand that the goal of the office is to provide me with test results in a timely fashion. If I do not hear from the office, I will call the office for test results. I understand that not hearing from the office about a particular test does not necessary mean that the test result is normal. I will inform my doctor if my medical condition changes, does not improve, or worsens. This will allow my doctor to re-evaluate my condition and make changes in treatment. If I do not inform my doctor, I may put my health at risk. 6) I will take charge of my health and make positive choices for my health including not smoking, not using illegal drugs, eating a healthy diet, and getting appropriate exercises. 7) I will treat all providers and office staff respectfully and courteously. 8) I will fulfill my financial obligations for care provided to me in a timely manner. 9) I will keep my scheduled appointments and give adequate notice of rescheduling or cancellation. 10) I will take responsibility to understand my Health Plan and be aware of my benefits, deductibles, and Health Plan limitations. I will ask my Health Plan if I have any questions regarding my health coverage. 11) If you need information or inquiring about Advance Directives (Durable Power of Attorney for Health Care. Natural Death Act Declaration or Living Will,) please call the Member Services Department of your Health Plan. I have read, understand, and agree to the above listed PRACTICE POLICIES 2 page form PRINT NAME DATE SIGNATURE Page 6 of 7
7 Patient Consent for Use and Disclosure of Protected Health Information 1) I hereby give my consent for John LaLonde, D.O. to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by John LaLonde, D.O. describes such uses and disclosures more completely.) 2) I have the right to review the Notice of Privacy Practices prior to signing this consent. John LaLonde, D.O. reserves the right to revise its Notice of Privacy Practices at any time. 3) A revised Notice of Privacy Practices may be obtained by forwarding a written request to John LaLonde, D.O Newport Blvd. Costa Mesa, CA ) With this consent John LaLonde may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. 5) With this consent, John LaLonde, D.O. may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and any items pertaining to my clinical care, including laboratory test results, among others. 6) With this consent, John LaLonde, D.O. may to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and any items pertaining to my clinical care, including laboratory test results, among others. 7) I have the right to request that John LaLonde, D.O. restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. 8) By signing this form, I am consenting to allow John LaLonde, D.O. to use and disclose my PHI to carry out TPO. 9) I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, John LaLonde, D.O. may decline to provide treatment to me. I have read, understand, and agree to the above listed practice information PRINT NAME DATE SIGNATURE Page 7 of 7
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DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. WELCOME LETTER 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL
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INSURANCE INFORMATION
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Office and Financial Policies
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of all prescription and non-prescription medications or supplements
Diplomate, American Board of Podiatric Surgery Fellow, American Board of Foot and Ankle Surgeons 1201 Medical Plaza Court Granbury, Texas 76048 817-578-8555 brazosfootandankle.com Dear Patient: Thank you
Welcome, If you have any questions about these policies and procedures, please ask one of our staff members for help.
Welcome, Thank you for choosing our practice for your orthopedic healthcare needs. On behalf of everyone at South Shore Orthopedics, LLC we welcome you to our practice. We strive to offer comprehensive,
Physical Therapy with care and knowledge
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A Great Opportunity for Very Valuable Healthcare Coverage
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NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
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Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
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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
Connecticut Asthma & Allergy Center LLC Registration Form
Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State
Consent for Services and Financial Policy
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Regain Natural Hormone and Wellness Center
Regain Natural Hormone and Wellness Center Name: Today s Date: Date of Birth: Age: Height: Weight: Street Address: City: State: Zip: Phone Numbers: Home: Cell: Email Address 1 Email Address 2 Employed
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
Welcome to our office
Welcome to our office I, the undersigned, realize that I am financially responsible for all services rendered to me by the Haben Practice for Voice & Laryngeal Laser Surgery, PLLC. For those insurances
PATIENT REGISTARTION
PATIENT REGISTARTION Patient Name: Last First MI Address: City: State: Zip Code: Tel # (h): Tel # (w): Cell #: S.S. #: DOB: Age: Email address: Male: Female: Marital Status Spouse or Parent Name Race Preferred
New Patient Registration Form. New Patient Update Date: / /
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FINANCIAL POLICY Woodbourne Family Practice believes that communicating our financial policy is good healthcare practice. Charges incurred for services rendered are the patient s responsibility regardless
Advanced Podiatry. W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted.
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