I understand, if at any time, I need to revoke or change this consent, I must submit
in writing to Tricity Family Medicine & Urgent Care Clinic, PLLC.
You may visit our website www.tricityfamily.com or ask staff to receive a copy of
detailed HIPAA policy- Notice of Privacy Practices.
I DO NOT authorize Tricity Family Medicine & Urgent
Care Clinic, PLLC to share my medical information with any other individual.
Insurance Information
Minor Patient
RESPONSIBLE PARTY- If the patient is a MINOR (under the age of
18), the parent or guardian bringing the patient in will be listed as the
guarantor.
FEES, PAYMENT & BILLING POLICIES
Your medical insurance policy is a contract between you and the insurance carrier.
Your coverage, the requirements for preauthorization, deductibles, co-payments and
co-insurance are all defined in your policy and their verification is your
responsibility. You
are responsible for all charges from the date of service. As a courtesy, we will
file all claims for our service with your insurance
company. Make sure that all the information you provided is accurate and up-to-date.
If we have not received payment from your
insurance company within 60 days of the date of service, you may be expected to pay
the balance in full. You are responsible to be
sure all charges are paid whether by you or by your insurance company.
We require all patients to sign a copy of our Patient Registration/Demographic Form
that assigns insurance benefits to be paid directly
to Tricity Family Medicine & Urgent Care Clinic, PLLC. In the event your insurance
company sends payment directly to you, it is your
responsibility to sign the check over to Tricity Family Medicine & Urgent Care
Clinic, PLLC.
We cannot waive any co-payments, deductibles or coinsurance amounts defined as
patient responsibility under the terms of our
contract with these various plans. If your insurance plan requires a co-payment,
such co-payment is due at the time of service;
otherwise, your appointment may have to be cancelled and rescheduled. For your
convenience, we accept Visa, MasterCard, Discover,
Care Credit or Debit Card.
NO Retro Billing - Please note if you have multiple health insurance
policies, it is your responsibility to provide us with accurate
information about each of your policy in the right order. Failure to do so, may lead
to payment reversal from your insurance eventually
and you will be responsible for outstanding balance at self-pay rate.
Missed Appointment Fee –Our office requests that if an appointment
needs to be cancelled that we receive notice no later than 24
hours prior to the appointment. We charge $25.00 for a “no show” appointment, to be
collected on or before your next appointment.
Returned Checks - There is a fee (currently $25) for any checks
returned by the bank.
NO Workers Compensation - Please note we DO NOT file workers
compensation claims.
After Hrs/Weekend/Holiday Charges
- There will patient responsibility of $25 for after hours if not covered by
insurance. After hours
are considered M-F before 8:00 am and after 5pm, weekends and holidays that we are
open.
Balances are due within 30 days of when the bill is issued-Bills will
be issued after the insurance carrier pays its portion of the bill.
Any outstanding balance that is 60 days overdue, a $15 Service Charge will be
imposed to help cover the costs involved in
continuously sending overdue bills. For any outstanding balance that is 90 days
overdue, your account may be forwarded to a
collections agency and be subject to a collection fee equivalent to 50% of the
unpaid bill.
I certify that I have read and agree to Tricity Family Medicine & Urgent Care
Clinic’s (TFMUCC) payment policy. I am eligible for the insurance indicated
on this form and I understand that payment is my responsibility regardless of
insurance coverage. I hereby assign to TFMUCC all money to which I am
entitled for medical expenses related to the services performed from time to
time by TFMUCC, but not to exceed my indebtedness to TFMUCC. I
authorize TFMUCC to release any medical information to my insurance carrier or
third party payer to facilitate processing my insurance claims. I
understand that failure to pay outstanding balances within 90 days of
notification of the amount due will result in submission to an outside
collection
agency. A $25.00 returned check fee will be charged for checks returned due to
insufficient funds. I choose to receive communication from TFMUCC by
text or email at the number or address stated above, including but not limited
to communications about appointments, treatment, and payment. I
understand that such emails and texts may not be secure and there is a risk that
may be read by a third party. I authorize the use of my signature on all
insurance submissions.
I have reviewed a copy of TFMUCC HIPAA Privacy Notice(
Initials)
Policy regarding Same-day Physical Exam & Office
Visit
Due to recent changes in your insurance payment policy, they REQUIRE your physical
exam/wellness care and your illness/follow up
care to be addressed in two separate visits. This will ensure the time and attention
required for each visit is met by the provider
To comply with your insurance payment policy, we WILL NOT address illness,
(foot/shoulder pain, cough/cold symptoms, rash, chest
pain, dizziness, etc.) OR follow up care for your medications, (such as
thyroid, anxiety/depression, hypertension, cholesterol, diabetes
medications/supplies, etc). This will have to be a separate visit from your
annual wellness/complete physical examination.
Wellness/complete physical examinations ONLY include a full exam and labs (as
deemed necessary by your provider). This will NOT
include thyroid panel or a hemoglobin A1C. The only medications that will be
addressed during your physical will be birth control pills,
for women only getting a pap.
For Tricare patients, NO referral will be given during a wellness/complete
physical exam EXCEPT for obstetrics (OB), if necessary
Adherence to this policy will help prevent claims from being denied by your
health insurance carrier. We realize the
inconvenience this may cause and regret that your insurance company’s payment policy
has led us to make this business decision.
Your understanding of this situation is appreciated.
By Signing below, I acknowledge I have read and understood the above regarding
Same-Day Wellness Care & Illness care policy. If
you do NOT adhere to this policy, you WILL be subject to the charges NOT
covered by your insurance carrier.
Prescription Refill Policy
-
No prescriptions will be refilled After hours, Saturdays, Sundays or Holidays by any of our on-call physician or provider for any
reason. The on-call providers are to be called for emergencies only.
-
The patient is responsible for knowing when medication(s) will need to be refilled.
-
Require 4 days minimum to process prescription(s) renewal and/or pick-up requests.
-
Non-controlled/non-narcotic prescriptions require a follow up appointment every 3 months.
-
Controlled-substances/narcotic prescriptions require a follow up appointment every 30 days
-
Before you come to your regular appointment, you should look over your medications, diabetes supplies, inhalers, etc. to
determine if you need to request any new prescriptions at your appointment.
-
Prescriptions will not be filled for “walk-in” patients (requested by walking into the clinic).
-
Any change to your medication treatment plan (increasing or changing medications) will not be made over the phone. It will
require a follow-up visit for re-evaluation.
-
We do require office visits on a regular basis for all of our patients taking prescription medication. It is very important to have
follow-up visit and/or blood work necessary for monitoring the safety or effectiveness of a medication.
-
New symptoms and/or events require a clinic appointment. Provider unable to diagnose via phone. If you think that you are
having an allergic reaction to a medication, call the office immediately or go to the nearest emergency room.
-
No early refills if medications are overused/abused/misused. Must follow prescription directions.
-
No medication/prescription will be replaced if lost, stolen, misplaced, overused, etc (treat like money!!).
-
Medications are for the prescribed individual’s use only. It is illegal to “share” your medicine.
-
Patient must pick-up his/her prescription(s) in person, unless pre-authorized by staff.
By signing below, I acknowledge I have read, understood and agree to adhere to
Prescription Refill Policy.