New Patient Welcome Letter

Donna Hurlock, MD, 205 S. Whiting St, Suite 303, Alexandria, VA, 22304 703-273-1533
PATIENT INFORMATION SHEET AND CONSENT FOR CARE AND PAYMENT
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Last Name
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First Name
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Middle I.
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Today’s Date
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Address
City
State
Zip
Social Security Number
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Date of Birth
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Marital Status
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Home Phone
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Occupation
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Work Phone
Cell Phone
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Employer
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Referred by
(Please indicate if “1” if needed
and any extensions needed.)
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Employer’s Address
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Spouse, Partner or Parent
Their Work Phone
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Their Employer
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Name for Emergency Contact
Relationship
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Their Phone
I the undersigned consent to the following items to be provided/performed by Donna Hurlock MD and staff.
_______ Consent to medical care considered necessary and proper in diagnosing or treating my condition.
_______ Consent to pay for these services at the time of the visit unless other arrangements are made in advance.
_______ Consent to the release of all information necessary to any third party payer if billing is submitted to that
third party payer by Dr. Hurlock or staff on my behalf.
_______ Consent to inform Dr. Hurlock or staff if I feel any adverse effect during any treatment.
_______ Consent to allow Dr. Hurlock to discuss my medical history with other physicians who may be involved
with my care.
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Your Signature (Or Guardian’s Signature)
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Today’s Date
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Financial Policy
April 2014
Thank you for choosing Dr. Hurlock as your physician. We are committed to your treatment
being successful. In return, we require full payment for our services at the time of the visit.
Please review the information below and enter the date and sign on the back to indicate that you
have read and fully understand our financial policy. If you do not understand any part, please ask for
an explanation.
1. INSURANCE: We do not participate with any insurance company, and therefore we expect
payment in full from the patient at the time of the visit. Any contract that you may have with an
insurance company is between yourself and that company. We are not part of that contract.
(Of course in most cases we recommend a Health Savings Account policy that dramatically
simplifies payment for out patient healthcare and minimizes the amount of your money that the
insurance company can keep for itself.)
2. REIMBURSEMENT BY YOUR INSURANCE COMPANY: At time of payment, we will
give you two copies of your “Superbill” which will include both the codes for any diagnoses
and for the services that we have provided. You can then attach this “Superbill” to your
insurance claim form to submit to your insurance company for reimbursement. Of course we
have no control over their payment policies.
3. FORMS OF PAYMENT: We accept cash, checks, Mastercard and Visa.
4. MEDICARE: Our status as far as Medicare is concerned is that we are “OPTED OUT”. This
means that Medicare will not pay either you nor us for Dr. Hurlock’s services. It is actually
against the law for you to submit to Medicare for reimbursement for Dr. Hurlock’s services.
You may submit to your secondary carrier however. On the bright side, Medicare patients are
not charged for any labs we do, instead, the lab that runs the test bills Medicare directly.
5. FEE SCHEDULE: Our fees are based on time spent with Dr. Hurlock, counted in 5 minute
intervals. The rate is $300 per hour, or $25 per 5 minute interval. Thus, a visit that takes only
15 minutes will be $75, while a complex visit that lasts 75 minutes will be $375. Time varies
with complexity of the problem. An average new visit can range from 60 to 90 minutes. The
more efficient we are at the visit, the less it will cost. Other services such as lab tests, pap
smears, injections and other procedures are billed as additional charges based on the particular
test or procedure. If you prefer to have requested blood tests at a lab that participates with your
insurance, we can give you a prescription for that at your visit.
6. COPY RECORDS FEE: Our fee for copying records is a base fee of $10, plus 25 cents per
page. (Virginia State Regulations, Virginia Code Ann. 8.01-413)
7. LETTER FEE: There may be a charge for letters requested by the patient, depending on their
complexity and time required.
8. PRESCRIPTION REFILLS FEE: Because it takes considerable physician and staff time to
pull and review charts in order to replace prescriptions, there is a fee for this service. Our fee
for replacing prescriptions is $10. This is charged in cases where you have lost your
prescriptions, let them expire, ran out of medicine because you did not schedule your follow up
visit on time, forgot to take your script to your mammogram visit, etc. If the replacement is
required due to our error, of course there is no charge. In cases where change of your insurance
company requires prescriptions to be transferred from one pharmacy to another, you can avoid
refill fees by having the original pharmacy TRANSFER the remainder of the script
directly to the new pharmacy.
9. MISSED APPOINTMENTS: If an appointment is missed (not cancelled with 24 hours or
more notice), there is a fee of $50, and $100 for a new visit (where 1 hour of time has been
allotted).
10. PAYMENT PLANS: In cases of financial hardship, you can arrange a payment plan with our
Office Manager.
11. RETURNED CHECKS: Our fee for returned checks is $25.00 plus any fee charged to us by
our bank.
12. FINANCE CHARGES: Our practice charges a fee for any unpaid balance after 30 days at a
rate of 1.5% per month overdue. Minimum monthly rebilling fee is $5.00. If your balance is
not paid in full within 90 days of the time of service, your account will be turned over to
collection agency. The patient will be responsible for any collection agency or attorneys’ fees.
Thank you for taking the time to read this carefully. Please let us know if you have any questions
or concerns.
I have read this Financial Policy and I understand and agree to this Financial Policy.
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Your Signature
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Today’s Date
Low Thyroid Symptom Check Off List
Name ___________________________________ Date ________________
Mild
Fatigue
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Weight gain
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Depression
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Anxiety
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Memory Issues
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Focus Issues (ADD)
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Migraines
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Poor Sleep
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Cold Intolerance
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Heat Intolerance
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Low Body Temperature _____
Hot Flashes
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Cold Hands/Feet
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Dry/Itchy Skin
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Dry Eyes
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Hair Loss
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Water Retention
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High Blood Pressure
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Cravings
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Constipation
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High Cholesterol
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Nasty Periods
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Irregular Periods
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Fertility Issues
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No Sex Drive
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Achy Joints
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Achy Muscles
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Tingling
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Sensitive to Medicines _____
Sensitive to Coffee
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Moderate
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Severe
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