New Patient Welcome Letter
Transcription
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 _____________________________ Last Name ______________________ First Name ______________ Middle I. ________________ Today’s Date ____________________________________________________________________ ___________________ Address City State Zip Social Security Number ______________ Date of Birth ____________ Marital Status __________________ Home Phone ___________________________ Occupation __________________ __________________ Work Phone Cell Phone ______________________________________ Employer ____________________________ Referred by (Please indicate if “1” if needed and any extensions needed.) _________________________________________________ Employer’s Address _____________________________________ __________________ Spouse, Partner or Parent Their Work Phone ______________________________ Their Employer __________________________________ _______________________ Name for Emergency Contact Relationship ____________________________ 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. _________________________________________________________________ Your Signature (Or Guardian’s Signature) ________________________ Today’s Date _________________________________________________________________ ________________________ _________________________________________________________________ ________________________ _________________________________________________________________ ________________________ _________________________________________________________________ ________________________ _________________________________________________________________ ________________________ _________________________________________________________________ ________________________ 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. __________________________________________________ Your Signature ______________________ Today’s Date Low Thyroid Symptom Check Off List Name ___________________________________ Date ________________ Mild Fatigue _____ Weight gain _____ Depression _____ Anxiety _____ Memory Issues _____ Focus Issues (ADD) _____ Migraines _____ Poor Sleep _____ Cold Intolerance _____ Heat Intolerance _____ Low Body Temperature _____ Hot Flashes _____ Cold Hands/Feet _____ Dry/Itchy Skin _____ Dry Eyes _____ Hair Loss _____ Water Retention _____ High Blood Pressure _____ Cravings _____ Constipation _____ High Cholesterol _____ Nasty Periods _____ Irregular Periods _____ Fertility Issues _____ No Sex Drive _____ Achy Joints _____ Achy Muscles _____ Tingling _____ Sensitive to Medicines _____ Sensitive to Coffee _____ _________________ _____ _________________ _____ _________________ _____ Moderate _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Severe _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____