IOANA A. BINA, M.D. Gastroenterology Tel: (707) 963-3311 Fax: (707)963-3322 (circle) Today's Date: Best Contact Phone# Cell Home Work PATIENT INFORMATION Name: Soc Sec #: Last Name First Name Initial Address: City: State: Zip: Email: Phones: Home Cell Work Sex: M F Birth Date Single Married Widowed Divorced Emergency Contact: Relationship: Phone#: PRIMARY INSURANCE INFORMATION Subscriber's Name: Last Name First Name Initial Relationship to Patient: Birthdate: Soc Sec #: Insurance Company: ID or Contract #: Group # Customer Service Phone# on back of card: Claims Mailing Address on back of card: ** You do not need to complete this information if you provide a legible copy of the front and back of your insurance card. SECONDARY INSURANCE INFORMATION Subscriber's Name: Last Name First Name Initial Relationship to Patient: Birthdate: Soc Sec #: Insurance Company: ID or Contract #: Group # Customer Service Phone# on back of card: Claims Mailing Address on back of card: ** You do not need to complete this information if you provide a legible copy of the front and back of your insurance card. FINANCIAL AGREEMENT (See Financial Policy / Conditions of Medical Services for Details on Options ) I agree I am responsible for any charges whether or not paid by insurance. I agree my charges will be paid by: Credit or Debit card on file OR Prepayment of all estimated copayments, co insurance, and deductibles Responsible Party Signature Date
Ioana A. Bina, M.D. Conditions of Medical Services & Financial Policy We require you read and sign this prior to establishing a relationship with us. Medical Consent: I consent to the treatment and/or procedures I may receive today. I understand that additional consents may be necessary for some tests/procedures. Protected Health Information: I received a copy of the Notice of Privacy Practices which describes when and how the practice may use or disclose my medical records This notice is given to all new patients at their fist vis, and is always available upon request. Insurance: Proof of Insurance: I agree to provide Dr. Bina s office with accurate and current insurance information and will bring my card to each visit. Participating Status: Dr. Bina contracts with most PPO and HMO Health Insurance Plans. Dr. Bina is also a participating provider with Medicare, Partnership Health Plan and Medi Cal. I a g r e e i t i s my responsibility to verify participation status directly with my insurance and will check with my insurance company if I am not certain if Dr Bina is a provider for my specific insurance plan. Insurance Coverage: I accept responsibility for knowing what is covered by my particular insurance plan and that I am ultimately responsible for payment of all services provided. Insurance Billing: I understand that the office will bill my primary and secondary insurance companies as a courtesy on my behalf; however, I accept for any remaining balances due. Explanation of Benefits: After Dr Bina s practice submits a claim, I understand I will receive an Explanation of Benefits (EOB) from my Plan, outlining the allowable amount and what portion of this they paid directly to Dr Bina. If I do not receive this EOB or have questions, I agree to contact my insurance company directly. Assignment of Benefits: I hereby assign to Dr. Ioana Bina any insurance or other thirdparty benefits available for healthcare services provided to me. I understand I have the right to refuse or accept assignment of such benefits. If these benefits are not assigned, I agree to immediately forward to the Practice all health insurance and other third party payments I receive for services rendered. Release of Information: I authorize Dr. Bina to disclose and release all or any part of my medical records to any entity which is, or may be liable, for all or part of the provider charges including but no limited to the Social Security Administration, Healthcare Financing Administration, its intermediaries or carriers, or other third party carriers. I authorize the release of records necessary to assist in the reimbursement of benefits to which I may be entitled. I authorize the release and disclosure of any and all of my medical records to any other healthcare entity, including but not limited to, referring physicians, hospitals or other health care providers who may be of assistance in providing treatment or care. 4. Financial Policy Credit card on file: I understand Dr Bina s practice requires a credit or debit card with authorization to bill my card for any balance for which I am responsible. The practice
will bill my card on file within 7 days of receipt of payment and an Explanation of Benefits from both my primary and secondary insurances. Prepayment Option: I understand that if I choose not to leave a credit or debit card on file with Dr Bina s practice, I will be required to prepay for all estimated copayments, coinsurance, deductibles and procedure reservation fees in advance of any service performed. Appointment Cancellation Policy: o Office Appointments: As a courtesy to other patients, I agree to give Dr Bina s office a minimum of 24 hours notice, as a courtesy to other patients who require her care. If I fail to give 24 hours notice of cancellation (or rescheduling), or fail to appear at my scheduled appointment, I understand that Dr. Bina reserves the right to charge a $50.00 fee to my credit or debit card on file. This fee is not covered by my HMO or Health Plan (a noncovered benefit). I understand that refusal to comply with this provision may result in my discharge from this practice. o Scheduling an Endoscopic Procedure at the Hospital requires the coordination of many medical professionals. As a courtesy to them and other patients, I agree to provide a minimum of 72 business hours notice if I must cancel or reschedule my procedure. If I fail to provide 72 business hours notice of cancellation (or rescheduling) Dr Bina will charge a $100.00 fee to my credit card on file, or I will forfeit the $100 deposit I provided. This fee is not covered by my HMO or Health Plan (a non covered benefit). I understand that refusal to comply with this provision will result in an automatic discharge from this practice. Thank you for understanding our Financial Policy and Assignment of Benefits. Please let us know if you have questions or concerns. I read the Financial Policy. I agree to this Financial Policy and Assignment of Benefits. Signed: Date:
Ioana Bina MD Inc Credit Card Authorization Form (Mandatory for all patients) Patient Name: Date of Birth: The purpose of this form is to authorize Ioana Bina MD Inc. (Dr Bina) to retain a valid credit or debit card number on file for you as our patient. All patients are required to complete this form. This form will be kept confidential and only authorized staff will have access to the information. Your supplied credit card will be charged ONLY under the following circumstances: 1. Dr. Bina reserves the right to charge the credit card listed below monthly for all current patient balances under $800.00, including co pays, deductibles, co insurance and charges not allowed by your insurance company, including missed appointment fees. A receipt will be sent to your current address on file or emailed if you provide a valid email address. This notice serves as your consent to being charged for all current patient balances per above on your account. A representative from Dr. Bina will contact you regarding balances over this amount either via a phone call, email or statement. 2. Other than the conditions mentioned above, under NO circumstance will Dr Bina charge your credit card for anything not discussed personally with you. In conjunction with HIPPA regulations, all credit card information will be confidentially kept within our secure credit card program. Once your information is entered into the system no one will be able to access your full credit card number or CVV information. Acknowledged, Agreed & Accepted: Having read this form, my signature below acknowledges that I voluntarily give my authorization and consent to providing the requested information for my credit card to be charged accordingly for the conditions listed above. X X Patient Signature Date X X Staff Signature Date NAME AS IT APPEARS ON CREDIT CARD: BILLING ADDRESS: Please provide your card to our receptionist by calling our office during office hours, or stopping by to provide your card. She will enter the information into our secure system. No physical copy of your credit card # or CVV will be maintained in the office. Refusal to Complete Authorization: Refusal to complete and agree to this authorization dictates the following: Since there is no credit card on file with Dr Bina, Dr Bina will require prepayment of any estimated patient responsibility after your insurance pays or full fee if you have no insurance coverage. You also agree to pay any remaining balances due after prepayment and insurance payment within 30 days. In addition, a $100.00 retainer will be paid in advance to schedule any procedure and missed appointment fees will be required to be paid in advance of rescheduling a missed appointment. The retainer, or portion thereof, will be refunded within 10 days of insurance payment. X X Patient Signature Date X X Staff Signature Date