Please print and complete all the enclosed forms and bring them to your first appointment.

Transcription

1 Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for your appointment, please present your completed paperwork, all insurance cards, proper identification such as a driver s license, and copayment if required. Please remember to bring a list of the medications you re taking and any current laboratory and procedure results. If you have an insurance plan that requires a referral, you will need to contact your primary care physician and have them forward a referral to our office. We may not be able to see you if a referral is not on file with our office by the scheduled appointment date and time. If you had results sent over to our office from another facility, please call our office ahead of time to verify that we received everything prior to your appointment including a referral if applicable. Please arrive 30 minutes prior to your scheduled first appointment to allow us sufficient time to process your paperwork. Please arrive 15 minutes prior to your appointment time for future follow-up appointments to allow time for the check-in process. For more information about our practice, please visit us on the web at If you have any questions please call and thank you for choosing Greater Chicago Specialty Physicians. Sincerely, The Providers and Staff at Greater Chicago Specialty Physicians

2 PATIENT'INFORMATION' Patient s full name: Last First Middle Initial Address: Street Apt. No. City State Zip Code Sex: Marital Status: Date of Birth: Age Ethnicity (circle one): (1) Non-Hispanic (2) Hispanic (3) Refuse to Report Primary Race (circle one): (1) White (2) Hispanic (3) African American or Black (4) Asian (5) Native American (6) Native Hawaiian (7) Other Pacific Islander (8) Other Race (9) Unreported/Refuse to Report Language (circle one): (1) English (2) Spanish (3) Other Address (required for patient portal & Company mailings): Social Security #: Driver s License # State Home Telephone: Cell Phone: Fax: Employer: Work phone Employment address: _ Street City State Zip Code PARENT/SPOUSE: Name: Telephone: Employer: Telephone: EMERGENCY CONTACT Name: Telephone: Relationship: Address: Street Apt. No. City State Zip Code Patient/Guardian signature: Date:

3 INSURANCE)INFORMATION) Appointment Type (Circle): (1) New (2) Work accident (3) Auto accident (4) Other Patient Name: Last First Middle Initial Responsible party: Primary Insurance Company: Effective Date Policyholder s Name: Birth date: SSN: Plan Type: Policy/ID No. Group No. Secondary Insurance Company: Effective Date Policyholder s Name: Birth date: SSN: Plan Type: Policy/ID No. Group No. Other Insurance Information: Workmen s Compensation/Personal Injury (if applicable): Date of Injury: Attorney: Phone: Address: Send Claims to: Phone: Contact Name (adjustor): Claim #: Address: I hereby authorize Greater Chicago Specialty Physicians ( GCSP ) to release any and all medical information to the above named insurance carriers or their representatives (and or attorney) for the purpose of claims administration and evaluation, utilization review, and financial audit. I further authorize any person or entity responsible for the payment of my medical bill or any representative on their behalf to pay GCSP directly for charges of services rendered to me. I further understand that I am fully responsible for any financial balance resulting from insurance non-covered services, co-payments, deductibles, co-insurances and any fees/charges associated by sending my account to collections. I agree to have my records sent to any requesting legal agencies or insurance companies with the understanding that a non-designated party may inadvertently see such information. Patient/Guardian signature: Date:

4 PHYSICIAN)&)PHARMACY)INFORMATION) How did you hear about us? Physician Other Patient Friend Emergency Rm. GCSP Website Insurance Co. Other REFERRING PHYSICAN NAME: ADDRESS: _ PHONE: FAX: PRIMARY CARE PHYSICIAN NAME: ADDRESS: _ PHONE: FAX: PLEASE LIST ANY OTHER PROVIDERS PHARMACY Name Street Address City Phone Mail Order YES / NO YES / NO Electronic Prescriptions: Our electronic medical record program accesses your prescription/medication history in order for us to safely prescribe your medication. By signing this, you authorize us to do so. Patient/Guardian signature: Date:

5 OFFICE&AND&FINANCIAL&POLICIES&REV& & In order to reduce confusion and misunderstanding between our patients and the office, Greater Chicago Specialty Physicians (GCSP) has adopted the following general practice policies. If you have any questions about these policies, please discuss them with our Billing Manager at We are dedicated to providing the best possible care and service to you and we regard your complete understanding of our office policies and your financial responsibilities as an essential element of your care and treatment. Please notify our office immediately when your medical insurance, home address, or contact information has changed. Missed or Cancelled Appointments/Late Arrivals As a courtesy, we attempt to contact every patient to remind them of their appointment but cannot always guarantee this. However, it is the responsibility of the patient to arrive for their appointment on time. Cancellations must be received 48 hours in advance. We reserve the right to charge for missed, cancelled, or no-show appointments. Such fees are $30 for follow-up appointments and $50 for any new patient appointment or procedures. These charges are available for review with our Billing Staff. If you are a new patient, you are asked to arrive 30 minutes prior to your appointment to allow sufficient time to fill out and process your registration paperwork. For new patients who do not arrive at least 15 minutes prior to their appointment time or for established patients who are more than 10 minutes late, we reserve the right to ask you to reschedule and treat you as a late cancellation. If you are running late we recommend that you call our office to verify your appointment will be honored. If you are consistently late, cancel, or miss your appointments, your account will need to be paid in order to schedule another appointment. This may also result in you being discharged from the clinic. Appointment Frequency and Appointment Time Most patients require frequent office visits to follow their medical problems and medications. If you do not come to appointments as recommended by your doctor, your medication may not be filled and, in some cases, it may be necessary to terminate your care. We do not believe it is good medical practice to fill medications for patients who have not been evaluated at a reasonable frequency. We strive to see patients at their regularly scheduled appointment time but it is not always possible. Although we dedicate an appointment time slot for patients, not every patient can be evaluated and treated during these time slots. Your provider will spend as much time as necessary to take care of any patient s primary medical problem including yours if needed. This may cause a delay in seeing other patients on time and we ask for your understanding. In addition, to minimize any delays in seeing patients, we ask that our patients be on time because if patients run even a few minutes late, this will contribute to delays for the rest of the day. In addition, if you are being seeing for an appointment and a procedure is recommended, you may be asked to schedule that procedure separately or at another visit so as to not cause any additional delays with other patient appointments. Initial (Page 1)

6 OFFICE&AND&FINANCIAL&POLICIES&REV& & Prescription Refills and Prior Authorizations We request that you obtain refills during your office visit. Majority of prescriptions will be faxed or electronically prescribed to your pharmacy. If there has been an oversight, please have your pharmacy send us a refill request. Please plan ahead as refills may take up to 5 business days to authorize. We will only authorize refills during office hours. Medications will not be refilled if a patient continues to miss scheduled appointments or has not been evaluated by their physician in a timely manner as discussed in the Appointment Frequency section. The purpose of these appointments is to allow our doctors to discuss your clinical response to treatment, assess the continued need for medication, monitor for side effects to your prescribed medications, and review any other available treatment options. Prior Authorizations for prescriptions or procedures may take up to 4 weeks and in some cases longer depending upon the response time from the insurance company or pharmacy benefit manager. Referrals Some insurance company plans will require a referral from your primary care physician to see a specialist or to have a procedure. If this applies to you, it is your responsibility to make sure we have a referral on file to avoid any delays. If a referral is required but not on file, you agree to be responsible for any charges. If you have questions about your plan's policy, please contact the membership department of your plan. Insurance We participate in most insurance plans. It is your responsibility to contact your insurance plan to see if we are currently in network. If you have questions about your plan's benefit coverage, please contact the membership department of your plan. Please bring your current insurance card every time you visit our office. If your insurance card is not presented to us and on file, you will be treated as a self-pay patient and payment will be expected at the time of your visit. It is your responsibility to ensure we have your most current insurance information. Any denied claims resulting from incorrect insurance information will be billed directly to you. It is also your responsibility to be aware of your covered benefits including any co-pays, deductibles, and plan maximums. Any amount not paid by your insurance company is due within 30 days regardless of whether you receive a statement from us. Co-payments, Deductibles, Account Balances and Collections Co-payments, coinsurances, deductibles, and account balances are due at the time of service. If your medical plan determines a service is "not covered or not medically necessary you agree to be responsible for the charge. For any procedure, treatment, or visit for which you are responsible for payment or that is not covered by your insurance plan but for which you have agreed and signed an informed consent, full payment via cash, credit card, or money order is required prior to the service or start of treatment. You agree that in order for us to service your account or to collect any amounts you may owe, we or any third party with whom we contract with in regards to your account, may contact you Initial (Page 2)

7 OFFICE&AND&FINANCIAL&POLICIES&REV& & by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by , using any address you provide to use. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. All accounts 90 days past due after insurance pays, will be sent to collections. If the account is sent to collections, there will be an additional 35% fee added to the balance owed. You also agree that in the event of non-payment, you will bear the cost of collections, court costs, witness fees and legal fees, should this be required. Payment is due upon receipt of a statement from the office. We accept cash, checks, money orders, Visa and MasterCard. We reserve the right to charge a $10 statement fee to your account if more then 2 statements are sent to you and no payment is received within 30 days. Insufficient Checks If a check is presented on insufficient funds you will be responsible to redeem the check in our office on a cash basis for both the amount of tender and a $35 service charge. Forms/Copies of Records Completion of any forms that requires your provider's input can be very time consuming for both the staff and your provider. You may be asked to schedule an appointment with your provider to assess and complete the requested information. An office visit will be required if it is has been 4 months or more since you have been seen by your doctor so they may assess your current state of health. A fee of $25 will be charged for all forms that are 2 pages or less and $50 for any forms more then 2 pages. More extensive forms, such as disability forms, may be charged $75. All forms require a minimum of 10 business days to complete and if a form is requested in less time then an additional $50 expedited fee will be assessed. We reserve the right to charge for copying of medical records. The fee schedule related with any requests for medical records can be found on the state of Illinois Comptroller website at You may also ask our billing department and obtain an estimate of the actual costs related to your request. All requests for patient medical records by other medical providers will be done free of charge. Disability Policy Your health care staff cannot become involved in any disability-related activity, including filling out forms for your employer or disability insurer, making a determination about your ability to do a job, communicating with an attorney, filling out any governmental form such as Family Medical Leave Act (FMLA), or parking handicap passes, etc, until you have seen your physician or physician assistant at least three times over at least 6 months. This is to insure we have developed as accurate a diagnostic picture and treatment plan as possible. Initial (Page 3)

8 OFFICE&AND&FINANCIAL&POLICIES&REV& & Test Results Our goal is to inform you of all lab results whether normal or abnormal. For various reasons, this may not occur or your provider may not have received results. It is the patient's responsibility to ensure they have been informed of their results and we request that if more then one week has elapsed since a test was done to give us a call to get your results. Don't assume they are normal or we received them. You understand that is your responsibility to provide contact information where you may be reached at all times as certain tests may require urgent attention. Results that require a detailed explanation will require an office visit to review. If you have signed up for our patient portal, your results may be communicated through your portal. It is your responsibility to make sure you access any communication from us sent to you through any method. General questions or new problems A telephone call can never replace an office evaluation of a problem. Brief questions to clarify confusion can be answered over the phone. New symptoms or complex questions will require a visit. It is our policy to require an office visit for any acute symptoms that may require an intervention such as a prescription or tests. You must make an appointment to get an evaluation, or go see your primary care physician or go the ER if we are not able to evaluate you in timely manner. Emergencies Please call 911 for all emergencies or go the ER. If you need immediate non-emergent care during non-office hours, please reach us through our answering service at the main office phone number and they will attempt to contact a physician. Patient Privacy The federal government requires us to share our Privacy Notice, which is made available at your initial visit to our practice and is available on our website. Please review the Privacy Notice, which explains the policy on sharing patient information for treatment and billing issues. Acknowledgement I acknowledge that I have read the Office and Financial Policies. I clearly understand and agree to be bound by its terms and understand that agreement with this policy is necessary for treatment at this facility. I also understand that these policies may be updated at anytime without notice but can be obtained in person at our office or on our website. Patient / Guardian Name Patient / Guardian Signature Date

9 AUTHORIZATION*FOR*RELEASE*OF*PATIENT*INFORMATION* Patient Communication Authorization: Call regarding appointments Call regarding my medical and/or financial information Leave messages regarding appointments. Leave messages regarding medical information including test results Leave messages containing financial information (Please circle) Home Cell Work Home Cell Work Home Cell Work Home Cell Work Home Cell Work Please note: A confirmation call is a courtesy call to our patients. Although we do our best to make these calls, this is not a guaranteed service. Release of medical information: I give authorization to the employees of Greater Chicago Specialty Physicians ( GCSP ) to discuss my medical and/or financial information with the person(s) listed below. These person(s) will also serve as my emergency contact(s) unless I specify otherwise. (Please circle) 1. Financial Medical Name Relationship Phone 2. Financial Medical Name Relationship Phone 3. Financial Medical Name Relationship Phone By signing below, I authorize GCSP to contact me and release my information by the above methods. I also understand that if I sign up for the patient portal, I am authorizing GCSP to contact me via this method regarding any communication. I also understand that it is my responsibility to provide contact information where I may be reached at all times as certain tests may require urgent attention Print Name Signature Date

10 Notice'of'Privacy'Practices' EFFECTIVE'DATE'12/01/2011'''' Updated'03/03/2014' '''''''''''''' Acknowledgment of Receipt of This Notice I acknowledge that I have received a copy of Greater Chicago Specialty Physicians Notice of Privacy Practices, which describes how medical information about me may be used and disclosed and how I can get access to this information. Signature of Patient Print Name Date Signature of Authorized Representative Print Name Date

11 AUTHORIZATION*TO*TREAT*MINOR* Name of Child/Minor As the parent/guardian of the above-named child/minor, I hereby give permission to the physicians and staff at Greater Chicago Specialty Physicians ( GCSP ) to treat the child/minor in the event that a medical emergency arises and I am unable to personally consent to the treatment. I also agree to be responsible to GCSP for charges for medical services rendered. Parent/Guardian Name Signature Date

12 Authorization+for+Release+of+Medical+Records Please send a copy of this release with the requested records. PATIENT INFORMATION (Please print) Patient Name Date of Birth Social Security Number Address City Zip Phone RELEASE FROM: [Name of physician or facility releasing information] I authorize release of my medical record from Physician/Facility Address City Zip Phone RELEASE TO: [Name of physician or facility receiving information] Please send my medical record to: Physician/Facility Address City Zip Phone RELEASE INFORMATION Reason: [ ] Change of insurance [ ] Moving out of area [ ] Transfer of care [ ] Specialist consultation [ ] Personal file [ ] Other [ ] Legal RECORDS FROM THE TIME PERIOD: / / through / / Please release the following (check all that apply) ALL INFORMATION LAST THREE VISITS LAB REPORTS X-RAY REPORTS HOSPITAL REPORTS OTHER: Please allow 15 days for processing. Incomplete information will delay processing. Use of this information for any other than the stated purpose is prohibited. This information is for the use of the designated recipient only and cannot be provided to any other agency. CONSENT I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. YES NO Initials I authorize the release of HIV/HTLV/AIDS test results. I understand that I may be charged for copies provided Signature of patient, parent, guardian, or patient representative (Please circle.) Date Witnessed by Date Note: This consent is valid for 180 days. The signer may revoke it at any time except to the extent that action has already been taken.