Patient Name DOB Print First and Last Name of Patient Date of Birth MM/DD/YYYY Our goal is to provide and maintain a good provider-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully and initial. Appointments We value the time we have set aside to see and treat your child. We do not double book appointments. If you are not able to keep an appointment, we require a 24-hour notice. There is a charge of $50 for missed appointments. If you are late for your appointment, we will do our best to accommodate you. However, your visit may need to be rescheduled. We strive to minimize any wait time; however, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding. The practice offers appointment reminders by text message, email and phone. Please let us know how you wish to receive reminders and other notifications from us. I want to OPT IN to receive phone messages for appointment reminders and practice communication. It is okay to leave an appointment reminder or a practice notification on my voice mail, with an individual, and on my answering machine. I want to OPT IN to receive text messages for appointment reminders and practice communication. Cell# I want to OPT IN to receive email messages for appointment reminders and practice communication. Email address I want to register for the Secure Patient Portal. My email address is: Initial: 1
Healthcare Policy Information Insurance plans and policies vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. We make every effort to verify participation and benefits prior to your visit, but you are responsible for knowing your benefits. Identification cards have a Member Service phone number listed on the back of the card. We strongly suggest you call Member Services to confirm participation and benefits before every visit to avoid any unexpected expense. Please understand, we are required to accurately report all services provided to the patient. It is possible your healthcare policy may apply co-insurance, deductible or a co-pay. Should this occur, you will be notified by your healthcare plan on the Explanation of Benefits and we will mail a statement to you. Prompt payment of your financial responsibility to the practice is appreciated. If we are your primary care physician, make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your primary care physician, you may be financially responsible for your current visit. Initial: Please initial beside each statement to acknowledge that you have read and agree to each statement of responsibility. To provide complete, accurate and timely healthcare policy information for the patient. To notify the practice if there is more than one healthcare policy; to include Medicaid, Peach Care 4 Kids and/or CMO coverage. Notify the practice within 3 business days, in writing, of changes, terminations, additions to your healthcare policy Respond within 3 business days to requests for additional information from our practice or billing company. Failure to respond timely or provided needed information in order for us to submit a claim for services could result in your healthcare policy denying the claim and you will become financially responsible for unpaid charges. Failure to respond timely or provide accurate information not only delays processing but it could result in denial of the services as well as a $15.00 reprocessing fee. Initial: 2
Financial Responsibility 1) Co-pays are collected at the time of Check-In (Regardless of who is accompanying the patient (if under the age of 18yrs) 2) Uninsured patients are required to pay a deposit prior to services rendered and the balance is collected upon completion of the visit. 3) According to your healthcare policy, you are responsible for any amount that is not covered by your policy, applied to deductible, co-insurance amounts and co-pays 4) The practice will not be involved in any domestic disputes. Legal documentation is required in order to change custodian or guarantor. It is your responsibility to provide us with legal documentation identifying who is financially responsible. 5) Your healthcare policy will send you and the practice an Explanation of Benefits after each claim is processed. This document identifies what your healthcare policy paid and according to your individual policy, what your personal financial responsibility is. 6) Patient balances are billed immediately on receipt of your insurance plan s explanation of benefits. Your remittance is due within 10 business days of the date on the bill. 7) If previous arrangements have not been made with our practice, any account balance outstanding longer than 28 days will be charged a $15 re-bill fee for each 28-day cycle. Any balance outstanding longer than 45 days will be forwarded to a collection agency and be charged a $25.00 collection agency fee. 8) We accept cash, checks, and major credit cards. A $35.00 fee will be charged for any checks returned for insufficient funds. Initial: Forms 1) Form 3231 is provided when a required immunization is administered according to Georgia s required immunizations for school. 2) Form 3300 is provided when a required screening is performed according to Georgia s required screenings for school. 3) Refer to the practice s Form Request Policy for School Forms in the event of a lost or misplaced form and other Clinical Forms. There is a nominal fee per form. 3
Referrals 1) When possible, please provide advance notice for non-emergent referrals. Typically 3 to 5 business days is appreciated. 2) Please be sure to confirm the selected specialist participates in your plan and is on your policy. We make every effort to verify this information. However, it is not possible for the practice to remain current on all specialists and what plans he or she participate with. 3) Please notify the practice should you choose to see a specialist without a referral. Transfer of Records 1) Please refer to Records Request Policy. 2) Some requests may incur a nominal fee for processing and copying. 3) Requests may take up to 30 days for processing. Prescription Refills 1) For monthly medication refills, we require 48 hours notice, during regular business hours. Please plan accordingly. Generally, these prescriptions are refilled electronically to the pharmacy we have on file. 2) For ADHD medications or any other controlled substance, please allow 5-7 business days for processing and these prescriptions must be mailed. I,, (Please print first and last name) (Relationship to Patient) Have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously. Responsible Person's Name Responsible Person s Signature Date Upon request, a copy of this completed form will be available. 4
Consent to Treatment I consent to treatment necessary for the care of my child/dependent. I authorize the release of all medical records to the referring and family physicians and to my insurance company, if necessary. I understand that payment of charges, including co-payments, deductibles and co-insurance is due at the time of service. I have been given an opportunity to review and request a copy of the HIPAA Notice of Privacy rights. I have read and fully understand the above consent for treatment, financial responsibility, release of medical information and insurance authorization. Signature of Parent/Legal Guardian (Guarantor): Date: Additional Information: In case of divorce, please do not place our office in the middle of marital disputes. It is your responsibility to work out the payment of your child s medical care between the custodial and noncustodial parent. We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact our billing department promptly for payment arrangements and assistance in the management of your account. 5