If you marked yes to insurance, you must complete the Primary Insurance information fields. If you have a secondary, you must complete the information fields. These fields are required. If you are truly self pay, type 'self pay' into the required fields. If proper insurance information is not provided, you agree to be personally responsible for charges. Please note, we do not accept medicaid. We do accept accept a wide variety of PPO commercial plans and limited HMO plans. Contact the office directly for further information regarding accepted insurance plans. Insurance will be verified prior to the appointment.
From time to time it may be necessary for a representative of Apple Ridge Family Medicine to contact patients for various notification purposes that could include disclosure of Protected Health Information such as:
· Appointment reminders/confirmation/rescheduling
· Prescription renewal/reminder information
· Lab/Imaging test results
· Requests to call the doctor for other issues
We would like to know how we can contact you and with whom we can leave a message or share other information about your Protected Health Information.
*If I have authorized contact via email, I understand that the message may not be encrypted and therefore security from an unauthorized access cannot be guaranteed. I further understand that Apple Ridge Family Medicine cannot guarantee receipt of message.
Apple Ridge Family Medicine appreciates the confidence you show in choosing us to provide for your health care needs. The services you have elected to participate in, implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of your fees. As a courtesy, we will bill your insurance carrier/s on your behalf. However, you are ultimately responsible for payment in full of your bill.
Many insurance companies have additional stipulations that may affect your coverage. It is ultimately the patients/guarantor’s responsibility to know your coverage benefits. I authorize Apple Ridge Family Medicine to furnish information to insurance carriers concerning my care. You are responsible for any amounts not covered by your insurance. If your insurance carrier denies any part of your claim, or if you elect to continue services past your coverage/policy period, you will be responsible for your balance in full.
You are responsible for the payment of any deductible, co-payments/coinsurance as determined by your contract with your insurance carrier. Some health insurance carriers require the patient to pay a co-pay for services rendered. This is a contract between you and your insurance carrier. Payment of all co-pays is expected at the time of service is rendered for the patient. If you do not have the co-pay, you may be asked to reschedule.
We understand that things happen where you can’t make your appointment. We do ask for a 24 hour notice in cancellations and rescheduling’s. If you do not show for your appointment, please note this is how Apple Ridge will handle no shows and improper notice of cancellations.
You are allowed the following within a 365 day period. The policy resets 365 days from the first offense.
· Your first ‘No Show’ is a verbal warning. One of our staff members will call you and alert you to the no show. If this is an improper cancellation notice, you will receive the verbal warning at the time of your phone call.
· Your second ‘No Show’ or improper cancellation notice would be a charge of $50 dollars. You would be verbally notified of this charge.
· Your third ‘No Show’ or improper cancellation notice would result in a discharge from the practice. This is not guaranteed to be told you verbally. You would receive a letter within 3-4 business days of the third ‘No Show’. That letter explains to you the policy and that you will receive thirty (30) days of emergency care by the practice. This would be the time we advise you to search for another physician.
Please note we have a policy that if you arrive 10 minutes late for an appointment, you will be asked to reschedule. This does not fall into the ‘No Show’ or improper cancellation notice policy. We will simply need to reschedule your appointment. We will do our best to accommodate you based on the physician’s schedule. This policy is in place to not disrespect other patient’s appointment times.
I authorize Apple Ridge Family Medicine, 1311 Biglerville Road, Gettysburg, PA 17307 to obtain my previous medical records. Please include my entire record from your facility, along with any old records you may have from previous physicians. The phone number to this facility is 717-334-8165 and the fax number is 717-338-9070.
Purpose of Release of Information : Transfer of Primary Care
This authorization will expire in 1 year from date of Signature
I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive this records. I understand that revocation will not have any effect on the actions taken prior to any revocation and will not apply to information that has already been released in response to this authorization.
The authorization is voluntary. I can refuse to sign this authorization.
I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the information may no longer be protected by federal privacy regulations.
I understand that this information may be re-release by the recipient and no longer protected.
I understand that the provider named above may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
If mental health records are being release as permitted by the Mental Health Procedures Act, I understand that I have a right, subject to 55 Pa. Code 5100.33 to inspect the material being released.
If AIDS of HIV- related information is being released, this information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or is authorized by the Confidentiality of HIV- Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.
By signing below, I certify that I understand the nature of this release.