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7 1855 Veterans Park Drive, Suite 201 Naples, FL Phone: (239) Fax: (239) Attention Patients: If you are scheduled for a preventative medicine visit (i.e. Well-Visit, preventative medicine, or a yearly physical exam) this visit will be submitted as a preventative exam to your insurance. Depending on your health plan s policy your insurance MAY or MAY NOT cover this visit. You may have a maximum annual cap for well benefits that is less than our charges. If during the course of your preventative exam the physician addresses and documents a problemrelated issue (i.e. hypertension, depression, diabetes, pain, acne, etc.) you may also receive an office visit charge, for instance, your insurance may require you to pay two co-pays and/or deductible/coinsurance amounts for that visit. For insurance purposes, if both the physical and problem-related issues are addressed in the same visit, the preventative visit is considered a separate charge from the office visit (problem-related issues) this is because these are separate identifiable services which would typically be taken care of in a follow up visit. If your provider addresses these problems regardless if they were performed on the same day, your insurance will be charged for an office visit in addition to the preventative charge. The physician cannot alter the coding submitted to your insurance in order for your insurance to make payment. The physician assigns codes according to the services provided regardless if they were performed on the same day; the patient assumes responsibility of any additional charges. If you have any questions, please contact the billing department. Signature and Acknowledgement: In signing this document, I have read, understand, and agree to the above information. Patient/ Patient Representative Name (Printed): Signature: Date:
8 1855 Veterans Park Drive, Suite 201 Naples, FL Phone: (239) Fax: (239) Appointment No-Show Policy: It is the policy of Hobdari Family Medicine to monitor and manage appointment no-shows. This is necessary to ensure that we are able to provide timely access for all patients to our providers. Undue numbers of unutilized appointments delays necessary medical care for patients. Scheduled appointments must be cancelled or rescheduled at least 24 hours prior to the scheduled appointment time. Any patient who fails to arrive for a scheduled appointment without cancelling the appointment at least 24 hours prior to the scheduled is considered a no-show. Office appointments which are not cancelled or rescheduled with 24 hours notification may be subject to a $50.00 cancellation fee. Front office supervisor may exercise limited discretion in assigning no-shows so as to account for special circumstances. These special circumstances shall be narrow in scope and would meet the general test of an unavoidable circumstance experienced by the patient such as hospitalization, or other emergency. Signature and Acknowledgement: In signing this document, I have read, understand, and agree to the above information. Patient/ Patient Representative Name (Printed): Signature: Date:
9 1855 Veterans Park Drive, Suite 201 Naples, FL Phone: (239) Fax: (239) Patient Consent Agreement For Chronic Care Services: Medicare now offers a new benefit for patients with multiple chronic diseases, and by consenting to this agreement you designate your provider, Lindita Hobdari, MD., to provide chronic care management (CCM) services per Medicare guidelines. Only patients with more than one chronic condition are eligible for this benefit and your provider agrees not to bill Medicare for this service if you do not have more than one chronic condition. Medicare defines a chronic condition as one that is expected to last at least 12 months, and that increases the risk of death, acute exacerbation of disease, or a decline in function. Provider Chronic Care Services: As part of this new benefit, your provider agrees to make available the following services: 1. 24/7 access to a healthcare provider to address your acute chronic care needs 2. Use of certified HER software to document your care 3. Provide a written or electronic version of your care plan 4. Perform medication reviews and oversights 5. Assist in the management of transitions of care from one provider to another In connection with this new benefit your provider agrees to bill Medicare just one time per each 30-day billing cycle and if you revoke this agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation. Beneficiary Consent Terms: By signing this agreement, you agree to the following terms required by Medicare: You consent to your provider providing CCM services to you 1. You acknowledge that only one practitioner can furnish CCM services to you during a 30-day period 2. You authorize electronic communication of your medical information with other treating providers to facilitate the coordination of care 3. You understand that the Medicare co-insurance amount applies to CCM services 4. You have the right to stop CCM services at any time by revoking this agreement at the end of the current 30-day period by notifying our practice in writing Signature and Acknowledgement: In signing this document, I have read, understand, and agree to the above information. Patient/ Patient Representative Name (Printed): Signature: Date:
10 Dr. Hobdari s Beautification Procedures Price List Individual Procedures Botox - $18.00 per unit Radiesse - $ per syringe Juvederm/Restylane - $ per syringe Belotera - $ per syringe Voluma (Cheek Augmentation) - $ per syringe Kybella - $ per vial Sculptra - $1250 per vial Myer s Cocktail - $ per IV treatment Glutathione Package - $ (includes 4 injections) $40.00 per injection Laser Treatments (ALL LASER APPOINTMENTS REQUIRE CONSULTATION) Laser Consultation - $ (*required*) IPL (Sun Damage) - $ Rejuvenation/Wrinkle Treatment 3, Stretch Mark/Scar Treatment 3, Skin Tightening - $3, Spider Vein Treatment - $ per leg Hair Removal (dependent on treatment area) Upper Lip Hair Removal - $ Laser Deposit - $ Chin/ Eyebrow/Face/Neck $ Aeriola Area - $ Under Arm - $1, Upper Arm/Forearm - $ Bikini Full - $1, Brazilian Bikini - $1, Upper/Lower Leg - $1, Full Leg/ Back - $2,000.00
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Patient Information. Insurance Information. Emergency Contact
Page 1 of 2 Name: Patient Information RVC-A1 Social Security Number: Gender:!Male!Female of birth: Mailing Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Insurance Information Name of policyholder:
Dear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
307 West Central Street Wendy J. Parker, M.D. Natick, MA 01760 Deborah J. Riester, M.D. Telephone: 508-820-8383 Jo-Ann Suna,M.D. Fax: 508-820-0250 Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang,