ANNUAL WELLNESS AND PREVENTATIVE EXAMS INFORMATION REGARDING BILLING AND INSURANCE Due to changes in health care laws, we are required to distinguish and bill separately for annual wellness exams and new problem visits. Your insurance company may refer to the annual visit as a wellness or preventative exam. These types of health maintenance exams are very limited and include only: A review of your general health A review of preventative testing appropriate for your age A review of your medications and vaccinations A general physical exam If we identify new medical issues during the visit, we can address these concerns at the same visit, but we are required to bill separately for things such as: Adjusting medications for a chronic medical condition Treatment for an acute illness or injury Making referrals for complex medical issues Ordering lab tests prior to or after the exam Your insurance may not pay for such an annual exam, or may pay for only a small portion of such an exam. We do not base our care on what an insurance company will pay, but rather on what is good medical care. Our office cannot code or bill an examination differently in order to obtain payment. Please do not ask us to disguise an annual exam as a problem oriented visit in order to receive reimbursement from your insurance. This is considered insurance fraud and is illegal. Our office will submit claims to insurance companies for collection of blood samples and pap smears which are sent to outside labs. Those labs will submit separate claims to insurance and may bill you for the actual processing of those tests. I have read this statement and understand that this visit will be billed as a preventative, annual or wellness visit. I understand that additional charges may be submitted for actual management of specific medical problems. I agree that I am responsible for all charges not paid for by my insurance company. Signature: Date:
What you should bring to your Annual Wellness Visit The names of all of your doctors: Name Specialty A list of all of your medications: Name of Medicine Dose Have any of your close relatives had any health changes? Yes No Has your mood changed? Yes No Do you worry about falling? Yes No Are you worried about your memory? Yes No Are there any preventive tests you have done recently? Yes No Have you had any recent immunizations? Yes No Do you have a living will or advance directive? Yes No (If you have one, please bring a copy with you.)
Prescription Refill Policy Please monitor your medications. Contact your pharmacy for a refill before you run out. Your pharmacy will fax a prescription refill request to our office. Note that we require a 48-hour advance request for all refills and do not refill prescriptions on weekends, so plan accordingly. Calling South Island Medical rather than your pharmacy may result in delayed prescription refills.
SOUTH ISLAND MEDICAL HEALTH HISTORY FORM Name: Date: Reason for Visit: Allergies/Sensitivities: Past Surgeries: PAST MEDICAL HISTORY: Check if you've been treated for in the past High Blood Pressure High Cholesterol Liver Disease Diabetes Thyroid Problems Kidney Disease Heart Disease Stroke Seizures/Epilepsy Reflux Disease Arthritis Cancer Stomach Problems Intestinal Problems Abnormal PAP Glaucoma Kidney Stones Tuberculosis Prostate Disease Pneumonia Osteoporosis Blood Clots Hepatitis HIV Psychological Issues Ear/Sinus Issues Asthma Fainting Menstrual Problems Sickle Cell Disease Other Concerns: Family History of Serious Illness: Occupation Alcohol Use Transportation/Housing Difficulties Hobbies/Interests Tobacco Use Difficulty preparing meals Do You Exercise? How often? Immunizations (circle): Shingles Pneumonia Flu Tetanus/Whooping Cough Tests you ve had (circle): Colonoscopy Fecal Blood Testing Mammogram Pap Smear PSA Rectal Exam Other practitioners you see Your local pharmacy: Your mail order pharmacy:
SOUTH ISLAND MEDICAL REGISTRATION FORM Today s date: PATIENT INFORMATION PCP: First: Last: Middle: Marital status (circle one) Social Security No.: Single / Mar / Partnered / Div / Sep / Widowed Is this your If not, what is your legal name? (Former name): Birth date: Age: Sex: legal name? q Yes q No / / q M q F Street address: Cell Phone No.: Home Phone No.: ( ) ( ) P.O. Box: City: State: ZIP Code: Occupation: Employer: Employer Phone No.: ( ) Email address: Preferred method of contact: (Please give your insurance card to the receptionist.) INSURANCE INFORMATION Person responsible for bill: Birth date: Address (if different): Home Phone No.: Is this patient covered by insurance? Subscriber s name: / / ( ) q Yes q No Subscriber s S.S. No.: Patient s relationship to q Self q Spouse/Partner q Child q Other subscriber: Name of secondary insurance (if Subscriber s name: applicable): Copayment: Birth date: Group No.: Policy No.: / / $ Group No.: Policy No.: Name of local friend or relative: IN CASE OF EMERGENCY Relationship to patient: Home phone No.: Work phone No.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize South Island Medical or insurance company to release any information required to process my claims. Patient/Guardian signature Date
FINANCIAL POLICY South Island Medical is committed to providing the best possible medical care. The following information outlines financial responsibilities related to payment of services. If you have questions regarding our financial policy or your insurance, contact our office. There may be certain coverage issues that will need to be directed to your insurance carrier. PATIENT RESPONSIBILITIES Patients are ultimately responsible for all charges associated with their care Patients must bring their insurance card and picture ID to every visit Patients may be required to obtain referrals and/or authorizations required by their health plans Patients must pay their co- pay amounts at each visit CONTRACTED INSURANCE PLANS South Island Medical (SIM) contracts with a variety of insurance plans. If you are covered by one of these plans, SIM will bill the plan directly. You are responsible for any outstanding balances after your insurance processes the claim. CO-PAYMENTS AND DEDUCTIBLES Co-payments and deductibles are a contract responsibility between you and your insurance carrier and may not be negotiated with SIM. Co-payments are due at the time of service. NON-CONTRACTED PLANS If SIM is not contracted with your insurance carrier, SIM will submit a one-time courtesy billing to the carrier. If payment to SIM is not received within 30 days, all charges are the patient s responsibility and are due immediately. PATIENTS WITHOUT INSURANCE Payment is due at the time of the visit unless other arrangements are made. A cash discount is extended if the bill is paid at the time of service. PATIENT FORMS The patient is responsible for charges associated with completing forms required for supplemental health care, disability, family leave or other forms requested that the patient s insurance carrier did not request. ADDITIONAL CHARGES AND FEES SIM will apply a fee for checks returned for non- sufficient funds. SIM may charge for missed appointments or for cancelling less than 24 hours prior to the appointment. UNPAID BALANCES SIM may assign outstanding patient balances to an outside collection agency. I authorize SIM to release any information required to process insurance claims and I authorize my insurance company to make payment directly to South Island Medical as appropriate. I agree to pay any outstanding charges within 30 days of receipt, unless payment arrangements have been made. Patient Signature Printed Patient Name Date