New Hope. New Life. New Beginnings. A Division of MID-ATLANTIC WOMEN S CARE, PLC OFFICE POLICIES PLEASE READ CAREFULLY AND INITIAL AFTER EACH.
|
|
- Scot Dominic Day
- 5 years ago
- Views:
Transcription
1 New Hope. New Life. New Beginnings. A Division of MID-ATLANTIC WOMEN S CARE, PLC OFFICE POLICIES PLEASE READ CAREFULLY AND INITIAL AFTER EACH. BOOKING POLICIES Your initial consultation represents a significant amount of clinic time, which is reserved for you to see the physician, Financial Counselor, and our Clinical, IVF, or Third Party Reproductive Care Coordinator. It is for this reason we charge a $125 fee for noshows and failure to cancel within 72 hours (3-business days) of their scheduled appointment. Your follow-up visits, depending on the type and nature of the appointment, will typically range from 20 to 40 minutes of clinic time (exception is treatment plan consultations with a physician) and require 24-hour notice to cancel or reschedule. Failure to provide the required notice will result in a $25 fee. No-shows will also be charged a $25 fee. The clinic may have to suspend further appointment bookings until the fee is reconciled. Office Consultations and Other Visits: New Patient Deposit, Time Allotted for Appointments, Services to Anticipate During a Visit, etc. NEW PATIENT - DEPOSIT & METHOD OF PAYMENT: A deposit of $125 is required at the time of booking your New Patient/Initial Consultation. We accept Visa or MasterCard credit or debit card payments via phone and we do not accept checks via mail. CASH PATIENTS: A second payment is due at the completion of your initial visit for the balance of your consult fee. This amount will depend on the level of your visit, but will range from $35 to $55. Patients electing to proceed with a PAS-US (Pelvic Anatomy Ultrasound) at this same visit, will incur this additional fee and their balance payment would instead range from $385 to $405. Any laboratory-blood tests performed this day will be billed by LabCorp directly. INSURANCE PATIENTS: Patients with insurance coverage for their New Patient visit and services will be credited or refunded their deposit less any applicable co-payment, cost share, deductible, and non-covered service costs due for their visit. NEW PATIENT CONSULTATION VISIT CASH PATIENTS: Patients without health insurance (or) with an insurance plan our office does not participate with, are as sessed a deposit fee in the amount of $125, payable at the time of booking the New Patient visit, and no later than 3 business days prior to the date of the scheduled appointment. The New Hope Center accepts Visa or MasterCard credit and debit card payments, and does not accept checks via mail. At the completion of your New Patient/Initial visit, a second payment will be due for the balance of your consultation fee. This amount will depend on the level of your visit. Patients electing to proceed with a PAS-US (Pelvic Anatomy Ultrasound), or other testing (HSG, bloodwork, etc.) at the initial visit will incur additional fees accordingly. Any laboratory-blood tests performed on this day will be billed to you direct by LabCorp.
2 INSURANCE PATIENTS: Patients with a health insurance plan our office participates with, must provide their policy ID (mem ber number) and group number, in order for our staff to contact the insurance carrier and perform a verification of coverage/ benefits. Patients with a health plan that does cover their New Patient/initial visit, will be responsible for paying their specialist co-payment, cost share, plan deductible (if not met), and any non-covered service costs, at the time of their visit. Patients whose health plan does not cover their New Patient/initial visit, will be assessed a deposit fee in the amount of $125, payable no less than 3 business days prior to the date of their scheduled appointment. For this reason, our office re-quires a valid credit card number be placed on file with your account. At the completion of your visit, a second payment will be due for the balance of your consultation fee, and any additional non-covered services provided during your visit. FOLLOW-UP VISITS: Test Results: NHC office staff cannot give initial fertility test results (i.e. CD#3 or AMH labs, HSG, Endometrial Biopsy, Semen Analysis, etc.) over the phone. Once you ve completed the initial testing, and our office has received your reference laboratory/blood test results, your physician will instruct one of our staff to contact you to arrange a Test Results Visit. This appointment is typically scheduled for 20 to 30 minutes, and is strictly to review your test results. Telephone appointments cannot be booked for these appointments with the exception of out-of-town patients. If you would like the physician to prepare a recommended treatment plan for you to discuss at this same time, then you will instead require a TREATMENT PLAN CONSULTATION rather than a TEST RESULTS VISIT (see below). Consultations: Such as: Post Surgery, Next Steps, Treatment Plan, or Specific Advanced Therapies-IVF, Donor Egg, Donor Embryo Consults - range from 40 to 60 minutes: We are committed to providing you with the highest quality of patient care, which is why your physician will periodically recommend a consultation. This visit may entail outlining a new or alternate treatment plan, recommendations for surgery or additional testing, a review of recent treatment or surgical procedures, or outlining the benefits of or providing an overview of a more advanced A.R.T. treatment protocol (i.e. IVF, Donor Egg IVF, etc.). Since the physician schedules can fill-up quickly, it is important to book these appointments as soon as possible, to ensure a day/time that fits into your schedule, as well as one that is not more than a week or two out. Whenever possible, we ask that your partner (if applicable) accompany you to these appointments. Our scheduling staff will do their best to assist you in booking an appointment that accommodates your work schedule as closely as possible, whenever possible. Start of a Treatment Plan and Ultrasound Visits: When beginning a new treatment plan, such as a Natural Cycle, Clomid/Femara Cycle, or an Ovulation Induction (OI) Cycle, your first visit will include meeting with a Clinical Assistant to review and sign your treatment consent form(s) and to receive pertinent medication instructions, a baseline ultrasound performed by the ultra-sonographer or one of the physicians, and a blood draw for hormone level testing. Those patients without insurance coverage will also meet with a Financial Counselor to make payment for their services/cycle. This visit may range from ~40 to 60 minutes.
3 Patients beginning an IVF, Donor Egg, or FET cycle are typically scheduled for either a pre-cycle endometrial biopsy (or) a hysteroscopy/d&c, approximately one to two weeks prior to their cycle start. This visit will range from ~30 minutes to 90 minutes (the latter if having a hysteroscopy). Patients doing these more advanced A.R.T. cycles are also scheduled for a Baseline Visit, a few days prior to starting their medications. This visit will include several procedures/services: a baseline ultrasound and cervical cultures, a blood draw for hormone level testing, meeting with a member of the IVF team for medication teaching/instructions, a meeting with a member of our Embryology Lab team to review and sign their ART consent forms, and finally a meeting with a Financial Counselor to handle payment for the cycle services and to schedule their next appointment. This visit may range from ~50 to 90 minutes, and is patient specific. Each patient receives personalized attention at the NHC; our staff want to ensure you are comfortable with the medication instructions for your protocol, as well as having answered all of your questions pertaining to the A.R.T. consent forms you will be signing. We ask patients to allot enough time for this visit so they do not feel rushed, should the appointment run longer than expected. We greatly appreciate your patience during these visits. Follow-up treatment ultrasound visits (all cycles) - typically range from 20 to 30 minutes, are scheduled every 2 to 4 days, and will include an ultrasound, blood draw, and medication instructions. These visits are typically scheduled with an ultra-sonographer, and you may not see a physician this day. As such, should you have specific questions that need to be answered by a physician, please advise with the clinical assistant at the time of your check-in, so they can check the availability of a physician. If one is not available during your visit, either a physician or one of our clinical staff will follow-up with, within 24 hours, with this information. Should you experience symptoms which require trouble-shooting on a day that occurs between your follow-up visits, please call our office, and we can book you for a quick 10-minute appointment to be seen. ARRIVAL FOR APPOINTMENTS: The physicians and other providers do their best to stay on schedule and we ask for your cooperation to do so. If you arrive late for your appointment, your appointment with your physician will be shortened or you may be asked to reschedule. Early arrival for scheduled appointments allows for the necessary check-in/interview process in preparation for your visit with the physician or provider. For this reason, we request New Patients to arrive a minimum of 30 minutes prior to their scheduled appointment time, and all other patients (consults, follow-ups, ultrasound visits, annual exams, weight management, etc.) to arrive a minimum of 10 minutes prior to their scheduled appointment. Evaluation and Management via Phone and ; Emergency Services; and Payments & Financing TELEPHONE CALLS: Our phone lines are open Monday to Friday 8am to 4:30pm. Our telephone lines are very busy and your patience is appreciated. Please keep your messages brief and include your full name and telephone number and one of our staff will return your call as soon as possible.
4 Important: Please leave only ONE message - leaving repeated messages only increases the amount of time required for our staff to process through the messages, and may result in delaying staff s ability to return your call. *For LAB & CLINICAL CALLS: Our Clinical and IVF staff, return follow-up lab test calls after 12 noon each day. Requests received at 4:00pm or later, are handled on our next business day. Based on the days volume of calls/inquiries, staff may return your call as late as 6:30pm. For this reason, please provide our office with the best telephone number for staff to contact you, and one that staff can leave a detailed message with your requested information on voice mail, if you are unavailable to receive their call. *For PRESCRIPTION REFILLS: When calling to request a prescription refill please be certain to provide your full name, date of birth, the name of the medication, and the name and telephone number of the pharmacy you are requesting the refill be called/faxed to. Our Clinical and IVF staff address all prescription refill requests after 12 noon each day. Requests received at 4:00pm or later, are handled on our next business day. If using a local pharmacy, make certain to contact their facility directly, to inquire/confirm your prescription has been filled and is ready to be picked up. Mail order pharmacies take ~48 hours for process and delivery. These pharmacies typically charge additional fees for expedited processing and delivery requests with less than 48 hours notice. *Telephone-Evaluation & Management Services: SEE BELOW under S-Evaluation & Management Services for information and fees related to this type of service. S- Evaluation & Management Services Our staff and physician s NHC addresses are for general office communications only. For your medical safety, requests received at these general addresses must be converted to our EMR system for a secure response to be made. This transmission requires patients to access the response information using a password. While it is not common place for our specialty and physicians to practice medicine via telephone or , we do understand that some patients as a result of work schedules or living out of town, may require or request such services. While our physicians, providers, and staff do their best to accommodate patients needs/requests, this type of management does require time and work, and as a result our office charges for these evaluation and management services. Since this type of service is generally not covered by insurance plans, patients are charged and financially responsible for the fees assessed. *FEE for and Telephone E&M Services: A fee ranging from $50.00 to $ is assessed and will be charged to your credit card on file with our office. The exact fee is determined by the type and extent of evaluation and management services and the time required of the physician. For example: A request for information regarding a recommended test, such as an H.S.G., might result in a $50.00 fee, while a request to discuss or prepare a new fertility treatment plan would typically result in a $ fee. *ALTERNATIVE We highly recommend patients contact our office and schedule a face-to-face appointment with a provider to discuss their medical care, whenever possible. To assist patients in requesting, confirming and even rescheduling appointments, we offer a secure web based appointment system called demandforce.com. This system also allows our office to provide patients with appointment reminders for upcoming appointments via and text message.
5 At the time of scheduling your new patient appointment, please provide your address and cellular telephone number to our scheduling/reception staff. When doing so, you will receive an and text invitation from our office (and this system) to participate in this free service; please respond yes or confirm accordingly. This will allow you the convenience of receiving appointment reminders, as well as the ability to request or confirm appointments with our office in this fashion, even during hours that our office is closed or our phones are turned over to service. EMERGENCY SERVICES Our office is open Monday-Friday from 8am to 5pm. If you have an urgent medical concern, our office staff will contact one of the physicians during office hours. If you are in need of emergency services after office hours, call 911 or go to your nearest hospital emergency department. You should notify our office the next business day (or during business hours) of your visit to an ER. A physician will be informed, and one of our staff will contact you with the physician s instructions or orders, if your condition is/was in relation to your current treatment with our facility. FRAGRANCES Due to the sensitivity of some of our patients, we ask that you wear no fragrances such as perfume, cologne, after-shave or strongly scented lotions on the day of your appointment. PAYMENT & FINANCING for TESTING AND TREATMENT: Our office accepts payment via cash, Visa & MasterCard credit and debit cards, as well as cashier s and bank drafted checks. We require valid credit card information be kept on file with our office. This allows for easy payment of telephone and/or Evaluation & Management Services (if/when provided), as well as outstanding balances for unpaid co-payments or cost share. You will be asked periodically to verify and update the card and information you have on file. To assist patients with additional funding, the NHC partners with several local banks, and three (3) online finance agencies. In addition, the C.A.R.E.S. Program is available to all cash patients, and includes discount packages for both infertility testing and treatment services. The C.A.R.E.S. Program affords patients a significant discount off the normal fee for service prices, and offers packages for Basic Infertility Testing; Clomid/Femara, Ovulation Induction, IVF, and Donor Egg IVF cycles. PAYMENT & FINANCING for TESTING AND TREATMENT: Medical services rendered- including diagnostics- are not refundable. Payment is expected at the time of service, for all patient responsible monies due for procedures performed and ser-vices rendered. Patient Name: Date:
6 NOTE: COMING SOON!!! Patient Portal and Electronic Bill Pay online at Website Coming Soon
WELCOME TO OUR PRACTICE
Nicole Schertell, ND / Johanna Mauss, ND 501 Islington Street, Suite 2B Portsmouth, NH 03801 Ph: 603-610-8882 Fax: 603-463-0943 WELCOME TO OUR PRACTICE Vibrant Health is an integrated medical clinic that
More informationAdministrative Form 1 4/20/2013 Version 1.1
TRINITY ALLERGY, ASTHMA AND IMMUNOLOGY CARE, P.C. NATARAJAN ASOKAN, M.D. 3931 Stockton Hill Road, Suite D, Kingman, AZ 86409 Tel. 928-681-5800 Fax. 928-681-5801 1971 Highway 95, Bullhead City, AZ 86442
More informationGeneral Office and Patient Compliance Policies
General Office and Patient Compliance Policies Thank you for choosing Innate Wellness & Medical Center as your medical provider. We are providing you this updated information to keep you informed of our
More informationThank you for choosing Oakland Medical Center as your Patient-Centered Medical Home
Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home We ask that you complete the enclosed paperwork and bring it with you at the time of your appointment. We also ask that
More informationC O M M U N I T Y H E A L T H C E N T E R S 1
C O M M U N I T Y H E A L T H C E N T E R S 1 Medical/Dental Home? A Patient Centered Medical/Dental Home is called a "home" because we would like it to be the first place you think of for all your healthcare
More informationPediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
More informationJohns Hopkins Travel Surgery Benefit FAQ
What is the Johns Hopkins Travel Surgery Benefit? The Johns Hopkins Travel Surgery Benefit is a special benefit sponsored by PepsiCo. The benefit offers members state-ofthe-art services focusing on heart
More informationGENERAL CONSENT FORM TO THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
GENERAL CONSENT FORM TO THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I understand that VeinSolutions, a division of Cardiothoracic and Vascular Surgeons creates and maintains medical and related
More informationCall Us at or Your appointment has been scheduled for at the Minnesota Men s Health Center, with Dr. Schow.
Call Us at 651-730-0775 or 888-685-3700 Date Dear Your appointment has been scheduled for at the Minnesota Men s Health Center, with Dr. Schow. Enclosed is the surgery scheduling agreement, health status
More informationWhat Makes MFM Associates Unique? Privademics - A New Method of Delivering Expert Care
We appreciate the confidence you have entrusted in us by choosing to become one of our patients. While we continue to keep pace with the latest advancements in health care, we never forget that each patient
More informationAPPOINTMENT INFORMATION SHEET
APPOINTMENT INFORMATION SHEET All appointments for new patients will require a one-time, refundable deposit of $50.00 to secure your appointment. You may use cash, check or credit card. The check or credit
More informationWelcome to Baptist Medical Group - Westside. Please read the below information carefully to prepare for your upcoming appointment.
BAPTISTMEDICALGROUP.ORG Westside Welcome to - Westside Please read the below information carefully to prepare for your upcoming appointment. Please arrive 15 minutes prior to your regularly scheduled appointment
More informationWelcome to BCHC Your Medical Home
START HERE 1 Welcome to BCHC Your Medical Home Thank you for choosing Berks Community Health Center (BCHC) as your medical home. This booklet gives you information about being a patient at BCHC and what
More informationRe-Vita -Life. Sub-dermal Bio-identical Pellets
Re-Vita -Life Sub-dermal Bio-identical Pellets Welcome and thank you for inquiring about Re-Vita-Life Bio-identical hormone replacement therapy. We have included a new patient information packet which
More informationBAPTISTMEDICALGROUP.ORG
BAPTISTMEDICALGROUP.ORG Primary Care - Nine Mile Dear Patient, Thank you for choosing Baptist Medical Group Primary Care - Nine Mile to provide you with compassionate care for your health care needs. We
More informationPLAN FEATURES PREFERRED CARE
PLAN DESIGN & BENEFITS - "HMO" PLAN FEATURES Deductible (per calendar year) $200 Individual $400 Family All covered expenses, excluding prescription drugs, accumulate toward the preferred Deductible. Unless
More informationPlease take a few minutes to read the enclosed information regarding the services offered at TOC and our general information and policies.
Dear New Patient, Welcome and thank you for choosing The Orthopaedic Center (TOC) for your orthopaedic care. We know that a healthy body is something many of us take for granted until illness, injury,
More informationWelcome to Ohio State s Dublin facility
Welcome to Ohio State s Dublin facility Preparing for your first visit Thank you for allowing The Ohio State University Veterinary Medical Center Dublin (VMC) to serve the healthcare needs of your pet.
More informationWelcome to Our Practice!
Welcome to Our Practice! We are thrilled that you have chosen us to be your pediatric practice and feel honored to participate in the heath care of your child! We welcome the opportunity to build a lasting
More informationPatient Name: Date of Birth:
: Patient Agreement Welcome to Community Psychiatry Community Psychiatry s dedicated providers and staff are committed to ensuring that each and every patient receives the highest quality psychiatry services
More informationBCBSNC Best Practices
BCBSNC Best Practices Thank you for attending today! We value your commitment of caring for our members your patients and our shared goals for their improved health An independent licensee of the Blue
More informationSchedule of Benefits
Schedule of Benefits ANTHEM Small Business Health Options Program (SHOP) This is a brief schedule of benefits. Refer to your Anthem Certificate of Coverage (Booklet) for complete details on benefits, conditions,
More informationThe Center for Liver Disease & Transplantation
The Center for Liver Disease & Transplantation P a t i e n t G u i d e Dear Patient, Welcome to the Center for Liver Disease and Transplantation (CLDT) at NewYork-Presbyterian Hospital/Columbia and NewYork-Presbyterian/Weill
More informationKaiser Permanente. An Integrated Health Care Model for Marsh & McLennan Companies Benefits Overview October 19, 2017
Presented by: Erica Elder Executive Account Manager Kaiser Permanente An Integrated Health Care Model for Marsh & McLennan Companies 2018 Benefits Overview October 19, 2017 Welcome! Our agenda for today
More informationNEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:
Patient s Name: NEW PATIENT PACKET Last Middle First Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone Email Address: Driver s License #: DOB: Gender: Male Female
More informationNew Patient Packet. Shawnee Health Care (618) Welcome to.
New Patient Packet Welcome to Shawnee Health Care www.shawneehealth.com (618) 519-9200 Table of Contents Page Welcome............................. 4 Our Mission............................ 4 Our Commitment
More informationOptional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
More informationPATIENT INSTRUCTIONS FOR PAPERWORK
330 Mallory Sta-on Rd., Suite B3 Franklin, TN 37067 Ph. 615-944-3530 Fax. 615-550.2641 PATIENT INSTRUCTIONS FOR PAPERWORK Thank you so much for trus0ng your care to Integra0ve Family Medicine. A
More informationWe want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.
Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed
More informationHouston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
More informationPREFERRED CARE. combination of family members; however no single individual within the family will be subject to more than the individual
PLAN FEATURES Deductible (per plan year) $500 Individual $1,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The family Deductible is a cumulative Deductible
More informationCONSENT FOR CARE AND ACKNOWLEDGMENT OF POLICES
DR. Frank Scot Elliott, M.D. Psychiatrist, PLLC Green Valley Psychiatric Associates 1090 Wigwam Pkwy #100 Henderson, NV 89074 (702) 454-0201 CONSENT FOR CARE AND ACKNOWLEDGMENT OF POLICES 1. Services provided
More information12 King Philip Rd. Sudbury, MA (585)
Dear Parents, In order to get started with speech therapy services including screening, evaluation, and treatment, we ask that you submit the following registration paperwork to Sudbury Speech and Language
More informationPATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.
PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples
More informationUser Guide for Patients
User Guide for Patients December 2016 Contents Health365 Overview... 3 What can I do with Health365?... 3 How to get started... 4 Sign In... 4 Home Page - Patient options... 6 Appointments... 7 To make
More information10711 Spotsylvania Avenue Fredericksburg, VA Phone:(540) Fax:(540)
10711 Spotsylvania Avenue Fredericksburg, VA 22408 Phone:(540)891-8499 Fax:(540)891-8662 FINANCIAL MATTERS We realize the need for a clear understanding between patient and doctor concerning financial
More informationPATIENT WELCOME PACKET
PATIENT WELCOME PACKET 1 Welcome! Welcome to the Virginia Hospital Center (VHC) Physician Group! We are a multi-specialty Physician Group consisting of primary care, urgent care, and medical and surgical
More informationTHE DAY OF YOUR SURGERY
Patient Guide Welcome Rockford Ambulatory Surgery Center provides a high-quality, convenient and comfortable setting for many outpatient surgical procedures. Your preparation and cooperation are important
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $250 Individual None Family $750 Family Unless otherwise indicated, the deductible must be met prior to benefits being
More informationLalita Matta, MD Estrela Chaves, NP, CDE
PERSONAL INFORMATION Name of Patient: Maiden Name: Social Security No.: Date of Birth: Home Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: Email Address: Race/ Ethnicity: Marital Status:
More informationPremier Surgery Center PATIENT S GUIDE TO OUTPATIENT SURGERY Erik Anderson MD
Premier Surgery Center PATIENT S GUIDE TO OUTPATIENT SURGERY Erik Anderson MD 3920 North Union Boulevard, Suite 240 Colorado Springs CO 80907 Phone: (719) 227-9711 TABLE OF CONTENTS: Information Preparing
More informationSHORELINE ALLERGY & ASTHMA ASSOCIATES, LLP
DORON J. BER, M.D., FAAAAI DANIEL L. WAGGONER, M.D., MAAAAI MAHESH NETRAVALI, M.D.,MAAAAI 23 CLARA DRIVE. BILLING DEPT: 860-536-8375 314 FLANDERS ROAD. MYSTIC, CT 06355 EAST LYME, CT 06333 860-536-2995
More informationmember handbook blueshieldca.com/bscbluegroove
member handbook blueshieldca.com/bscbluegroove With Main Groove, you get a Personal Physician from our medical provider network, and predictable, lower outof-pocket costs than with Basic Groove, plus access
More informationHouston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
More informationOptional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived 30% after deductible
PLAN FEATURES NON- Deductible (per calendar year) $500 Individual $750 Individual $1,500 Family $2,250 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and
More informationPatient Portal (Online Patient Services) Frequently Asked Questions
Patient Portal (Online Patient Services) Frequently Asked Questions Table of Contents I. General Patient Portal Questions II. III. IV. Appointment Scheduling Questions Prescription (RX) Refill Questions
More informationWELCOME. Enclosed is helpful information that will ensure your experience is the best it can be.
PATIENT GUIDE } 1 WELCOME At Baylor College of Medicine, your comfort, privacy and safety are our top priorities. In our experience, the more prepared you are, the more relaxed you will feel during your
More informationAt Rahav Wellness, we want you to feel comfortable before. embarking on your journey with us. We want you to understand how
NEW PATIENT GUIDE What to expect as a patient of Dr. Rahav At Rahav Wellness, we want you to feel comfortable before embarking on your journey with us. We want you to understand how the care we provide
More information714 Beacon Street, Newton Centre, MA,
Nancy Cooper, MD Kari Emsbo, MD Yana Urman, MD 714 Beacon Street Newton Centre, MA 02459 617-332-1001 Phone 617-332-5154 Fax Dear Patient: On behalf of all of us at Beth Israel Deaconess HealthCare-Newton
More informationComprehensive Pain Care, P.C. Patient Handbook. 840 Church Street Suite D Marietta, GA (770)
Comprehensive Pain Care, P.C. Patient Handbook 840 Church Street Suite D Marietta, GA 30060 (770) 421-8080 1 Welcome Welcome to Comprehensive Pain Care, P.C. Our staff is dedicated to providing pain relief
More informationWelcome Plan. Basic health insurance for temporary, new and returning Canadian residents
Welcome Plan Basic health insurance for temporary, new and returning Canadian residents Help your newest plan members feel at home Recognizing the skills and fresh perspectives that a diverse organization
More informationHEALTH SAVINGS ACCOUNT (HSA)
HSA FEATURES Health Savings Account Amount $600 Employee $1,000 Family Amount contributed to the HSA by the employer. Funded on a quarterly basis. HSA amount reflected is on a per calendar year basis.
More informationSummer Recreation/Adult Education Program
H E W L E T T W O O D M E R E PUBLIC SCHOOLS HEWLETT-WOODMERE PUBLIC SCHOOLS Summer 2 0 1 7 Recreation/Adult Education Program Registration begins Monday, June 12th Evening Registration: Mondays, June
More informationAn EPO Employee and Retiree Medical Plan...
An EPO Employee and Retiree Medical Plan... Member Handbook...with PPO Benefit Option The benefits and service you love. Plus. IMPORTANT CONTACT INFORMATION PLAN INFORMATION AND MEMBER SERVICES Office
More informationACTION CERTIFIED PERSONAL TRAINER WRITTEN EXAMINATION INFORMATION
7 ACTION CERTIFIED PERSONAL TRAINER WRITTEN EXAMINATION INFORMATION ELIGIBILITY You will receive an eligibility email from ACT, Inc. when you are eligible to sit for the exam. Once you have been approved,
More informationTHE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER
THE PAIN TREATMENT CENTER, INC. d/b/a STONE ROAD SURGERY CENTER PATIENT INFORMATION GUIDE 280 Pasadena Drive Lexington, Kentucky 40503 (859) 278-1316 Visit us on the Web at www.pain-ptc.com Dear Patients
More informationWELCOME to Kaiser Permanente
WELCOME to Kaiser Permanente PPO PLAN RESOURCE GUIDE Colorado kp.org/kpic-colorado Greetings Subscriber name, we re glad to be your partner on this journey, and we look forward to a long and healthy relationship
More informationComprehensive Dental Care Using General Anesthesia
UW MEDICINE PATIENT EDUCATION Comprehensive Dental Care Using General Anesthesia This handout provides the information you need to make an informed choice about having general anesthesia to complete your
More informationAmarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)
Today s Date: / / PATIENT INFORMATION Patient s Last Name First Middle Mr. Miss Mrs. Ms. Marital Status (Circle one) Single / Mar / Div / Sep / Widow Legal Name (If applicable) Maiden Name Birth Date Age
More informationWelcome To Our Practice
Maternal Fetal Medicine Associates, PLLC 70 East 90 th Street New York, NY 10128 Welcome To Our Practice We appreciate the confidence you have entrusted in us by choosing to become one of our patients.
More informationPEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D. 1506 KLONDIKE RD SW SUITE 205 CONYERS, GA 30094 678-750-4000 TELEPHONE 678-750-4005 FAX www.pcfwellness.com Dear Family, We are excited to welcome
More informationService Rendered EBCBS GHI Health Plan Notes Alcohol Detox/Rehab (IP or OP) Submit to GHI. Submit to GHI
New York City Account Claim Submission Guide The purpose of this guide is to help determine which insurance carrier to send a claim to for certain hospital versus medical services. For instructions on
More informationDear Prospective Patient,
Dear Prospective Patient, We appreciate your interest in pursuing your health with us. I started this integrative medical practice intending to take exceptional care of my patients in a manner that is
More informationProcedure Code Job Aid
Procedure Code 99211 Job Aid Definition for 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually,
More informationProvider Town Hall Presentation
Provider Town Hall Presentation Topics HAP & Health Care Reform Overview Healthy Engagement Reminder Healthy Michigan Plan HAP Midwest Health Plan Overview ICD-10 & HAP Provider Newsroom Updates 2 HAP
More informationPATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #
PATIENT INFORMATION PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # STREET ADDRESS CITY, STATE, ZIP HOME PHONE # CELL PHONE # WORK PHONE # Emergency Contact & relationship: Phone #: Pharmacies local and
More informationUpdated: 10/01/12 Page : 1
PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family
More informationPATIENT PORTAL USERS GUIDE
PATIENT PORTAL USERS GUIDE V 5.0 December 2012 eclinicalworks, 2012. All rights reserved Login and Pre-Registration Patients enter a valid Username and secure Password, then click the Sign In button to
More informationWelcome to the Office of Dr. Sam Van Kirk!
Welcome to the Office of Dr. Sam Van Kirk! We understand that you have a choice in selecting your healthcare provider and we are pleased that you picked our practice. Our goal is to provide respectful,
More informationEffective Date 1/1/2014
Effective Date 1/1/2014 1 Tufts Health Plan Overview Tufts Health Plan in business for 30+ years Headquartered in Watertown MA, with regional offices in Providence RI, Worcester and Springfield More than
More informationColumbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
More informationKaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION
Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION 2019 Summary of Important Changes for Contract Renewals for the Kaiser Permanente Group Plan (These changes are subject to regulatory
More informationL R C P. I n t h i s s e c t i o n, y o u w i l l f i n d : Parking information Maps. Information about patient and family centred care
L R C P L O N D O N R E G I O N A L C A N C E R P R O G R A M ( L R C P ) I n t h i s s e c t i o n, y o u w i l l f i n d : Parking information Maps Information about patient and family centred care Information
More informationPatient Registration Form
Date: Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Patient Registration Form First Name Middle Last Name... Sex: M F Date of
More informationWebsite: Tel: , Topaz Medical EMR. Official Users Guide
Release1.1b Christopher Christie, Systems Architect Website: www.topazemr.com, Tel: 876-384-0343, Email: c_christie2000@yahoo.com Topaz Medical EMR Official Users Guide Introduction Topaz EMR [Electronic
More informationForm B - For those enrolled in other insurance
Form B - For those enrolled in other insurance PATIENT REGISTRATION Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth
More information**IF YOU SHOW UP WITHOUT ANY OF THE LISTED ITEMS, WE WILL RESCHEDULE!!!**
Dr. Jasna Kojic 6000 Turkey Lake Rd. Suite 205 Orlando, FL 32819 PHONE: (407) 649-1848 FAX: (407) 649-1979 Dear Parent/Guardian of : We welcome you and your son/daughter to our office and are happy to
More informationOptional PREFERRED CARE. Covered 100%; deductible waived. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including prescription drugs, accumulate toward both the preferred and
More information$2,000 Individual. Deductible (per calendar year)
PLAN FEATURES Deductible (per calendar year) FAMILY PHYSICIANS GROUP $2,000 Individual $4,000 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost
More informationFACE SHEET Please type or clearly print
FACE SHEET Please type or clearly print Applicant #1 name: Applicant #2 name: State: Home Phone Alternate Phone #1 Alternate Phone #2 Mailing Address Email address: How much money are you requesting? (cannot
More informationCare Management Policies
POLICY: Category: Care Management Policies Care Management 2.1 Patient Tracking and Registry Functions Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure management and monitoring of patient
More informationNorth Cypress Medical Center Patient Portal is a secure, private web portal that allows you to access health information online.
North Cypress Medical Center Patient Portal is a secure, private web portal that allows you to access health information online. WHY USE THE PATIENT PORTAL? Manage and maintain your personal health information,
More informationScheduling & Physician/Staff Utilization
Scheduling & Physician/Staff Utilization Presented By Economedix Your Partner In Building High Performance Practices Today s Course Practice Management Seminar Series First of Four Patient Flow & Marketing
More informationGuide to Accessing Quality Health Care Spring 2017
Guide to Accessing Quality Health Care Spring 2017 MolinaHealthcare.com 5771749DM0217 MyMolina MyMolina is a secure web portal that lets you manage your own health from your computer. MyMolina.com is easy
More informationBETTER INFORMED. BETTER TOGETHER.
BETTER INFORMED. BETTER TOGETHER. easy to get appointments free to focus on my patients excellent prenatal care test results online I can choose my doctor wide range of specialists I m part of the decision
More informationMagellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program
Magellan Healthcare 1 Magellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare
More information12057 Jefferson Blvd LA, CA (323)
Playa Vista Mental Health General Adult and Women s Psychiatry 12057 Jefferson Blvd LA, CA 90230 (323) 813-6218 Please read and complete each of the sections listed below as completely as possible. NEW
More informationMedical History Form
Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies
More informationYOUR SURGERY MADE EASY
BASCOM PALMER EYE INSTITUTE ANNE BATES LEACH EYE CENTER YOUR SURGERY MADE EASY Welcome Anne Bates Leach Eye Center 900 NW 17 Street, Miami, FL 33136 305-326-6000 800-329-7000 (toll-free) Frequently Called
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA
PLAN FEATURES Deductible (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met
More informationDear Parents/Guardians,
Tel 410 601 8331 Fax 410 601 8859 Dear Parents/Guardians, We would like to take a moment to welcome your child as a new patient of Pediatric Endocrinology at the Herman and Walter Samuelson Children s
More informationPLAN DESIGN & BENEFITS
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) Poway Unified School District None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include
More informationPatient Information Booklet. Appointments
Patient Information Booklet The providers and staff of Orchard Medical Center S.C. would like to welcome you to our practice. Patient satisfaction is the commitment we make to every patient seen in our
More informationA letter to my patients,
A letter to my patients, As of April 1, 2018, Texas Family Physicians will change our practice model from Traditional Fee for Service to a Medical Membership model. Medical Membership is a hybrid between
More informationCareCore National & Alliance Provider Training Material
EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National & Alliance Provider Training Material Prepared for: March 6, 2014 Contents CareCore National... 3 Alliance and CareCore National Partnership... 4 Radiology
More informationVirginia Aquarium & Marine Science Center 2017 SUMMER DAY CAMPS REGISTRATION FORM. Participant s Name Birth Date Camp Title Camp Date Camp Fee
Virginia Aquarium & Marine Science Center 2017 SUMMER DAY CAMPS REGISTRATION FORM Please bring this completed form to on-site registration on April 5, 2017. Registrations will not be accepted by mail or
More informationMERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015
MERCY MEDICAL CENTER - DUBUQUE TRADITIONAL PPO PLAN $10/20%/40% RX PROVIDED BY PREFERRED HEALTH CHOICES EFFECTIVE JANUARY 1, 2015 DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS facilities and Aligned
More informationOpen Access PLAN DESIGN
PLAN FEATURES Deductible (per plan year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family All covered expenses accumulate separately toward preferred or non-preferred Deductible. Unlesss
More informationCadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE
Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Date: / / Name: Date of Birth: / / Age: Sex: M F ETHNIC ORIGIN: White Hispanic Haitian African American Other: PRIMARY LANGUAGE: English Spanish
More informationHCR ManorCare Advanced Heart Care Program FAQ
What is the HCR ManorCare Advanced Heart Care Program? The HCR ManorCare Advanced Heart Care Program with Cleveland Clinic is a special program through your company medical plan* that offers members state-of-the-art
More information