We look forward to seeing you at our office. Thank you for giving us the opportunity to serve you.

Transcription

1 Charles E. Castillo, M.D., F.A.C.S 2320 N. 3 rd Street Phoenix, AZ Welcome to the office of Dr. Charles Castillo. We appreciate the confidence and trust that you have placed in our office and look forward to meeting you personally and professionally. Our goal is to provide the highest quality care possible in a friendly, caring and efficient environment. Enclosed please find our new patient paperwork. Please bring this completed paperwork to our office for your first visit. We also ask that you bring the following items. Current insurance card Driver s license or government issued photo ID CD/Films for any CT scans Actual films for mammograms for all breast patients ( your appointment may be rescheduled if your films are not available) We are located on the northwest corner of 3 rd Street and Hoover, between Thomas and McDowell, just south of Virginia. Our building looks like a 2 story Spanish style house and the parking lot is on the north side of the building. We look forward to seeing you at our office. Thank you for giving us the opportunity to serve you.

2 NEW REGISTRATION UPDATED EIN ARIZONA ASSOCIATED SURGEONS, PLLC Allen Agapay, MD Ravia Bokhari, MD Jeromy S. Brink, MD John Brothwell, MD Charles Castillo, MD Edward Charles, MD Adrienne Forstner-Barthell, MD William Friese, MD Richard Harding, MD David Johnson, MD J. Michael Kassenbrock, MD Jon King, MD Mary Schultheis, MD Brett Siegrist, MD David Smith, MD Keith Zacher, MD PATIENT INFORMATION LAST NAME FIRST NAME MI BIRTHDATE AGE SOCIAL SECURITY # HOME ADDRESS CITY STATE ZIP SEX MALE FEMALE HOME PHONE # CELL PHONE # MARITAL STATUS: MARRIED SINGLE WIDOWED DIVORCED OTHER REFERRING PHYSICIAN NAME AND PHONE NUMBER PCP NAME & PHONE# HOW DID YOU HEAR ABOUT US: PROVIDER REFERRAL INTERNET WORD OF MOUTH PREVIOUS PATIENT CURRENT PATIENT BROCHURE INSURANCE HOSPITAL CONCENTRA MAGAZINE RADIO OTHER MANDATORY-PER NEW CMS GUIDELINES LANGUAGE ENGLISH SPANISH RUSSIAN CREOLE OTHER ETHNICITY LATINO/HISPANIC NON LATINO/NON HISPANIC RACE ASIAN NATIVE HAWAIIAN OTHER PACIFIC ISLANDER BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE WHITE REFUSE TO REPORT RESPONSIBLE PARTY INFORMATION (financial responsibility) LAST NAME FIRST NAME MI HOME PHONE ADDRESS CITY STATE ZIP SOCIAL SECURITY # EMPLOYER OCCUPATION WORK PHONE EMPLOYER ADDRESS CITY STATE ZIP RELATIONSHIP TO RESPONSIBLE PARTY SELF SPOUSE CHILD OTHER EMERGENCY INFORMATION NEXT-OF-KIN OR CONTACT INFO PHONE PHARMACY NAME AND LOCATION PHONE INSURANCE INFORMATION-SUBSCRIBER PARTY INFORMATION PRIMARY INSURANCE SUBSCRIBER NAME AND SOCIAL SECURITY DATE OF BIRTH GROUP NUMBER IDENTIFICATION NUMBER ADDRESS CITY STATE ZIP PHONE SECONDARY INSURANCE SUBSCRIBER NAME AND SOCIAL SECURITY DATE OF BIRTH GROUP NUMBER IDENTIFICATION NUMBER ADDRESS CITY STATE ZIP PHONE NUMBER ASSIGNMENT OF BENEFITS, FINANCIAL POLICY TERMS AND RECORDS RELEASE ASSIGNMENT OF BENEFITS I have read, agree to and signed the Arizona Associated Surgeons Financial Policy. I agree I will be responsible for any unpaid balances for any reasons. I hereby authorize direct payment to Arizona Associated Surgeons PLLC of any medical benefits payable to me for the services provided at Arizona Associated Surgeons. X Patient Signature or Signature of Guardian or Parent Date RECORDS RELEASE I hereby authorize Arizona Associated Surgeons PLLC to release my records to my insurance company and/or primary care physician for the purpose of processing my insurance claims. This authorization shall remain in effect as long as charges are being submitted for insurance claim processing or as long as dictated by payor. X Patient Signature or Signature of Guardian or Parent Date Revised:March 2015

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4 Patient Name: D.O.B. REVIEW OF SYSTEMS: Please put a check mark in the box next to any current symptoms you are experiencing. General o Fevers o Migranes Skin o Bruising o Itching o Rash Head and Neck o Hoarseness o Sinus Problems o Neck Mass Respiratory o Asthma o Chronic Cough o Difficulty Climbing 1 Flight of Stairs o Nightime Breathing Difficulty Cardiovascular o Chest Pain o Heart Disease o Irregular Heartbeat o Shortness of Breath o Heart Stent o Previous Heart Attack o Blood Clots o Pace Maker Gastrointestinal o Abdominal Pain o Bloating o Constipation o Diarrhea o Excessive Gas o Food Intolerance o Heartburn o Nausea o Vomiting Genitourinary o Difficulty Emptying Bladder o Kidney Problems o Kidney Stones o Recent Kidney/Bladder Infection o Excessive Urination at Night Musculoskelatal o Back Pain o Muscle Weakness o Arthritis Neurological o Decreased Memory o Head Injury o Seizures Psychiatric o Depression o Anxiety o Difficulty Sleeping Endocrine o Diabetes o Hormone Problems o Thyroid Problems Hematology o Anemia o Bleeding Problems o History of Blood Transfusion Date:

5 Financial Policies Thank you for choosing Arizona Associated Surgeons for your surgical needs. We are committed to providing you with the highest quality medical care and maintaining a good physician-patient relationship is our primary goal. Because patients are ultimately responsible for the charges associated with their care, even when insurance is in place by letting you know in advance of our office policies allow for a good flow of communication and enables us to achieve our goal. We realize you have choices for your medical care and appreciate you choosing Arizona Associated Surgeons. Patient Responsibilities You can help ensure an efficient experience by assisting with the following: Providing us with your picture identification, insurance card(s) and Social Security number to enable us to submit your claims timely and accurately Knowing your insurance benefits and limitations Ensuring there is a written authorization for our providers to treat you if it is required by your insurance, including obtaining a referral Providing us with copies of any pertinent medical records, including tests and x- rays Paying your estimated portion of the charges at the time of service and paying any additional amount owed when due Copays are subject to $25 surcharge if not paid at time of service Providing us with at least 24 hour advance notice should you need to cancel or reschedule an appointment to avoid No Show fees Please note that co- payments, co- insurance and deductibles are a contractual agreement between you and your insurance carrier. We cannot change or negotiate these amounts. Insured Patients For our patient s convenience we participate in most major health plans and have contracts with many HMO s, PPO s, insurance companies and government agencies including Medicare and Medicaid (AHCCCS). Our business office will submit claims for services rendered to a patient who is a member of one of these plans and assist you in any way we reasonably can to help get your claims paid. It is the patient s responsibility to provide all necessary information at the time the appointment is scheduled. If you have a secondary insurance we will 03/2015

6 automatically file a claim with them as soon as the primary carrier has paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. If you are insured by a plan we contract with but don t have an insurance card with you, payment in full for each visit is required until you furnish us with a copy of the card and your coverage can be verified. Co- Pays/Deductibles/Co- Insurance Please be prepared to pay for your portion on date of service Your insurance company requires us to collect co- payments at time of service. Waiver of co- payments may constitute fraud under state and federal law. For your convenience we accept cash, checks or the following credit cards: Visa, Master Card, Discover and American Express. If you do not have your co- payment your appointment may be rescheduled. Additionally, you may have co- insurance and/or deductible amounts due as required by your insurance carrier. Surgery If surgery is indicated, our office will collect as a pre- payment any remaining deductible you may have and any co- insurance due prior to your surgery. Your out of pocket cost is estimated based on your benefits and our fees. Anesthesia, facility and other providers are separate fees. Our office will provide written notification to you detailing anticipated charges. If your remaining deductible is not applied to our claim by your insurance company, a credit will appear on your account and a refund will be promptly processed and mailed to you. Motor Vehicle Accidents (MVA) Insured and Third Party Patients We do not extend discounts for MVA- insured accidents, third party insurance claims or in other cases when patients may be reimbursed in full. We will bill the MVA insurance carrier one time, the bill becomes your responsibility if not paid by the carrier in 30 days. We regret that we are not in a position to confer with attorneys or defer payment obligations while a case settles. Workers Compensation If your visit is work- related we will need the case number, date of injury, carrier name and phone number prior to your visit in order to bill the workers compensation insurance carrier. If your claim is not yet accepted, we will bill your private insurance and if uninsured payment in full is expected. Other Charges No Show - Please provide us with at least 24 hours advance notice if you need to cancel or reschedule an appointment, procedure/surgery. Failure to cancel a scheduled appointment may be subject to a $25.00 fee and failure to cancel a surgery/procedure may be subject to a $ fee. Forms There may be a charge associated with our completion of some forms. We require payment of the charge before returning the completed form to you. A signed Release of Information may also be necessary. Please allow 5 business days for us to complete the forms. 03/2015

7 Payment Payment Options - We accept cash, checks, major credit/debit cards and money orders for payment (no post- dated checks or third party checks). We charge a $40.00 NSF fee for any returned checks. Delinquent Accounts - We allow 30 days from date of filing for an insurance company to process and/or pay a claim. Arizona law allows insurance companies operating in the state no more than 30 days to process claims. It is your responsibility to provide your insurance company with requested information needed to process a claim. We may assign an account to collections if balances are unpaid after 60 days. Patients assigned to collections may be denied additional services. Patient balances are billed immediately on receipt of your insurance company payment or receipt of Explanation of Benefits (EOB). Your remittance is due within 10 business days of your receipt of your bill. Alternative Payment Arrangements If you are unable to pay your balance when due, please contact our business office at option 1 to make alternative arrangements. Any patient with a past due amount may be denied additional service until the amount is paid or the patient is complying with an alternative payment arrangement. Prior Bad Debt Patients, who have previously never satisfied their payment obligations for prior episodes of care with Arizona Associated Surgeons, will be required to pay those in full before receiving additional care. I have read and understand this office financial policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously. 03/2015

8 Patient Name(s) Responsible party member s name Relationship to patient Responsible party member s signature Date: 03/2015

9 ARIZONA ASSOICATED SURGEONS PLLC. ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE AND HEALTH INFORMATION NOTICE Patient Name: Date of Birth: I acknowledge that I have been provided the Arizona Associated Surgeons PLLC. ( Practice ) Notice of Privacy Practices: It tells me how Practice will use my health information for the purposes of my treatment, payment for my treatment, and Practices health care operations. The notice explains in more detail how Practice may use and share my health information for other than treatment, payment, and health care operations. Practice will also use and share my health information as required/permitted by law. I acknowledge that I have been provided the Arizona Associated Surgeons PLLC. ( Practice ) Notice of Health Information Practices ( Notice ): It tells me how Practice will electronically share health information with a Health Information Organization (HIO). The notice explains in more detail how I may Opt out of sharing my health information with the HIO. Signature of Patient or Personal Representative Name of Patient or Personal Representative Description of Personal Representative s Authority Date Address Telephone

10 Charles Castillo, MD Joni McIntyre, PA- C 2320 N 3 rd St. Phoenix, AZ Phone# Fax# Release and Authorization for Use or Disclosure of Protected Health Information Patient Name: Date of Birth: Address: Telephone: I authorize Arizona Associated Surgeons or other person/entity to disclose/release the following information: All medical records related to (specify condition, treatment, etc.): All billing records related to (specify condition, treatment, etc.): Specific records/information as follows: Purpose of disclosure: I do not want the following information disclosed (as defined by applicable state and federal laws): Alcohol/Drug Abuse HIV Test Results Mental Health/Developmental Disabilities Release information TO: Address: Telephone: Fax: This Authorization is good until the following date: Note: If this item is left blank, the authorization will expire in one (1) year from the date signed. YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: I am aware that I have the right to inspect and receive a copy of the health information I have authorized to be used and/or disclosed by this Authorization. I understand that I may be charged a fee for record copies. In addition, I understand that I do not need to sign this Authorization in order to receive treatment. I also am aware that I may revoke this Authorization by notifying the disclosing medical records/health information department in writing. However, I understand that my revocation will not be effective as to uses and/or disclosures: (1) already made in reliance upon this Authorization; or (2) needed for an insurer to contest a claim/policy as authorized by law if signing the Authorization was a condition to obtaining insurance coverage. I realize that the information used and/or disclosed pursuant to this Authorization may be subject to re- disclosure and no longer protected by federal privacy law. Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative Description of Personal Representative s Authority Date Address Telephone