FINANCIAL RESPONSIBILITY Name: Relationship: Home Address: Home Phone #: Cell Phone #: Date of Birth: Social Security Number: Employer: Occupation:

Size: px

Start display at page:

Download "FINANCIAL RESPONSIBILITY Name: Relationship: Home Address: Home Phone #: Cell Phone #: Date of Birth: Social Security Number: Employer: Occupation:"

Rosalyn Nicholson
5 years ago
Views:

1 LITTLETON OB/GYN ASSOCIATES 7750 S Broadway, Suite 200 Littleton, CO David J. Watson, MD Bruce R. Dorr, MD Jeannie Key, NP Jessica Anderson, NP WELCOME TO OUR OFFICE! DATE: PATIENT INFORMATION Patient Name: Marital Status: S M D W Patient Social Security Number: Home Address: of Birth: Age: Home Phone #: Cell Phone #: Work Phone # : Address: Employer: Occupation: SPOUSE /PARENT/GUARDIAN INFORMATION Name: Relationship: Home Address: Home Phone #: Cell Phone #: of Birth: Social Security Number: Employer: Occupation: FINANCIAL RESPONSIBILITY Name: Relationship: Home Address: Home Phone #: Cell Phone #: of Birth: Social Security Number: Employer: Occupation: EMERGENCY CONTACT (only if different from above) Name: Relationship: Home #: Cell #: Work #: WHO CAN WE THANK FOR YOUR REFERRAL TO OUR OFFICE? Doctor / Nurse / Friend / Family / Other: Your Primary Care Physicians Name: I AUTHORIZE THE RELEASE of any medical or other information necessary to process any health insurance claims. I authorize the payment of health care benefits to Ob/Gyn Affiliates for any medical care that I have not paid for. Patient/Parent Signature as agreed to above I AGREE TO PAY for any requested health care provided to me by Littleton Ob/Gyn Associates, P.C. at the time services are rendered for non HMO insurance. I understand that Managed Care HMOs, Point-of- Service and Preferred Provider Organization health plans may have co pays that I am responsible for when services are rendered to me and I agree to pay these on the day of service. I authorize payment directly to Littleton Ob/Gyn Associates for any insurance benefits. Patient/Parent Signature as agreed to above 1

2 HOW CAN WE REACH YOU? Your physician and staff members will, at times, need to contact you. By filling out the information below, we will be better able to serve you. LITTLETON OB/GYN ASSOCIATES, P.C. PHONE MESSAGE CONSENT In an effort to protect your privacy, we have developed a policy leaving medical information. We will NOT leave messages with anyone except the patient or legal guardian. We will NOT leave any information on an answering machine. We will NOT leave any messages on a voic . UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO. Please read below and consider carefully whom you want to have access to your medical information. I, give Littleton Ob/Gyn Associates, P.C. my permission to leave phone messages regarding my medical care and test results with following individual(s). I fully understand that this consent will remain until revoked in writing. My cell voic My home answering machine My office/work voic My spouse: Other: Signature: : 2

3 NOTICE AND ACKNOWLEDGEMENT Acknowledgement: I acknowledge that I have received the Notice of Privacy Pratices. Print patient or Personal Representative name Patient or Personal Representative signature If Personal Representative s signature appears above, please describe Personal Representative s relationship to the patient. 3

4 Littleton Ob/Gyn Associates, P.C. David J. Watson, M.D. Bruce R. Dorr, M.D. Jeannie Key, N.P. Jessica Anderson N.P South Broadway, Suite 200 Littleton, CO FINANCIAL POLICY Our Financial Policy Thank you for choosing us as your health care provider. Visiting a physician is like any other service-oriented company. While your health care is our primary concern, we are a business, and as such we expect payment at the time of service. Fees are based upon the services rendered, the physician s time, the skills involved and the cost of delivery of the service. We make every effort to keep the cost of your medical care down and you help by paying for your visit at its completion. All co-pays and deductibles are due at the time of service. This office provides excellent quality care and we are proud of our office and staff. We have been and always will be sensitive to our patients needs and encourage you to contact our office if a problem regarding your account should arise. Regarding Insurance Your insurance coverage is a contract between you and your insurance company. It is not possible for us to provide service on the basis that the insurer will always pay all charges. This is because coverage varies so greatly and because of PPO & HMO regulations. PLEASE READ YOUR SUBSCRIBER MANUAL CAREFULLY! We cannot bill your insurance unless you bring in your insurance identification card. For indemnity insurance plans, we require the percentage NOT paid by your insurance company be paid at time of service as well as your deductible. The balance is your responsibility whether your insurance company pays or not. If surgery is indicated, balance bill arrangements will be set up prior to your admission. If your indemnity plan insurance company has not paid your account in full within 90 days, the full balance will be your responsibility. Minors The adult accompanying a minor and/or the parents (or guardians) of the minor patient are responsible for full payment. For unaccompanied minors, nonemergency treatment will be denied unless charges have been pre-authorized to an approved credit plan or VISA/Mastercard, or payment by cash/check at time of service has been verified. The responsibility for payment for services rendered to any dependent child whose parents are divorced rests with the parent who seeks treatment. 4

5 Court ordered judgments are personal between parents and will exclude the involvement of our office. Co-Pay Policy It is the responsibility of the patient to pay medical care co-pays for each appointment, at the time of service, per the PATIENT'S contractual agreement with her insurance company. No-Show Policy It is the written policy of this office to accommodate our patients needs and schedules to the best of our ability. For this reason, we ask our patients to call us to cancel appointments they cannot keep, even if only able to give a twohour notice. We request 24 hours notice to make your time slot available to someone else. There is no charge for your first NO SHOW, however, any additional NO SHOWS will be BILLED TO YOU at $25.00 each and must be paid before further services will be provided to you. Non-Payment of Your Account In the event your account becomes delinquent, you will be responsible not only for charges incurred, but also any costs involved in the collection of your account. These include, but are not limited to, interest charges, re-billing fees, court costs, and collection fees. You are ultimately responsible for the payment of your account. I fully understand the FINANCIAL POLICY as written above. I understand that a photocopy of this agreement is as authentic as the original and will stand legally for the life of the patient/physician relationship. My signature below will be applicable for today and all future dates of services provided to me until I inform this medical practice otherwise in writing. Patient or Responsible Party Co-Responsible Party REVISED

6 Ob/Gyn Affiliates An Ob/Gyn Medical Group Administrative Offices 1745 Shea Center Drive, 4 th Floor Highlands Ranch, CO (office) (fax) TO BE COMPLETED ON VISITS FOR WELL WOMAN EXAMS : Patient Name: Doctor: Insurance issues, requirements and coverage are ever changing. We are making every effort to be in compliance and to eliminate payment denials before they occur. Your insurance plan may or may not cover routine preventative services (well woman exam). We are legally obligated to assign procedure codes based on the service provided to you, whether it is a well woman exam, a visit to take care of problems or both. We cannot change the coding later to cause the insurance company to pay for a non-covered service. Based on the kind of coverage you have, some or all of this cost may have to be billed to you. Please keep in mind that while the appointment may be just for a physical or just for problems, if both kinds of services are provided during a visit, then both services may be billed. If both services are billed, you may be responsible for paying a co-payment for each service, depending on your insurance coverage. Please indicate below the purpose of your visit as you understand it. We thank you for taking the time to complete this form. We are making every effort to comply with governmental rules and the rules of all insurance plans for claims submission. We appreciate the help of our patients in this endeavor. Well Woman Exam Problems (please list): Both Patient Signature 6

INSURANCE INFORMATION

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: