Patient Registration Form

I give consent for treatment(s), physical examination(s), and consultation(s) by Dr. Dhiraj Patel and Dr. Neil Patel. I fully understand that payment/copayment are required at the time of service. Should my insurance be filed, any unpaid balance is my personal responsibility. I further authorize the release of any medical information to my insurance company when necessary. In the event that insurance is filed by the doctors’ office, I authorize benefits to be paid directly to Alpha Medical Clinic. During the course of my treatment at Alpha Medical Clinic, I understand that there may be occasions for charges of non face-to-face visits, treatment recommendations, and/or review of records. I give my permission for Alpha Medical Clinic to bill my insurance company for these services and any amount deemed patient responsibility by the insurance company will be billed accordingly. Any outstanding balances of 90 or more days will be forwarded to a collection agency.

Insurance
We participate in most major commercial health insurance plans and Medicare. Knowing your health insurance benefits is your responsibility. Our office does not verify what your specific plan covers. Please contact your insurance company with any questions you may have regarding your coverage.
All patients must complete our demographic form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance card at the time of your appointment, you can be self-pay for your appointment.
Payments
It is your responsibility to pay any deductible, co-pay, co-insurance or any portion of the charge as specified by your plan. This is your contract with your insurance company. If you do not pay your co-pay upon checking out from your visit, you will have a $25.00 additional fee added to your account. Bounced checks will also have an added $25 dollar fee which must be paid before an office visit.
Please be aware that some (and perhaps all of the services, depending on your plan) you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You agree to pay any portion of the charges that is not covered by insurance.
Claims Submission
Please be sure to follow up with your insurance company regarding claim status. You are responsible for any balance on your account. If claims are unpaid after 90 days, they will be referred to a collection agency. We will file to both your primary and secondary insurance policy. We do not file to tertiary plans. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. If your insurance company does not respond within 60 days, you are responsible for the remaining balance. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
Balances
Unless other arrangements are approved by us in writing, you are responsible to pay your balances within 30 days of services being rendered. Once we send you a statement, the balance on your statement is due and payable upon receipt. Please be aware that if a balance remains unpaid, we will refer your account to a collection agency and you may be discharged from the practice. If this occurs, you will be notified by regular or certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physicians will only be able to treat you on an emergency basis.
Balances may be paid via mail, through our website alphamedicalonline.com or by calling us during business hours.
Workers Compensation/ MVA Claims
If you are being seen in our office due to a work related injury, you must bring the first report of incident form, which should include the original injury date, your claim number and the claims address that we are to file these claims for you.

We do not file motor vehicle claims. All patients being seen regarding a motor vehicle accident will be self-pay and must file their own paperwork with any 3rd party company. 

I have read and understand Alpha Medical Clinic's financial policy and agree to comply and accept the responsibility for any payment due as outlined previously.

PLEASE READ THIS POLICY IN ITS ENTIRETY AS WE ADHERE TO IT STRICTLY

• Refills for routine medications (not including scheduled/pain medications) will be processed within 2 business days ( excludes weekends and holidays) of receipt of the request.
• Refill requests from pharmacies are not accepted. To minimize errors inherent in automated refill requests, we require patients to request refills directly by calling our office during business hours.
• Patients are encouraged to keep a close eye on their medications and request refills in a timely manner.

Below are our procedures regarding refilling of medications:

• Maintenance medications such as those for Blood pressure, Diabetes,  Cholesterol,  and Thyroid will only be  approved if patient has had an office visit within the last 3 months unless otherwise directed by your provider.
• Narcotics, other controlled substances such as ADD/ADHD medication, anxiety medications, and sleep aids will require a mandatory office visit visit. No exceptions are made regarding this policy.
• Controlled prescriptions that are lost, stolen, destroyed, or otherwise misplaced CANNOT be reissued.
• Antibiotics will not be called in or refilled as an office visit is required for evaluation by the physician.

The following are conditions for immediate termination from the practice:

• Obtaining narcotics from other physicians while under Alpha Medical Clinic care.
• Please note we routinely communicate with pharmacists, your other physicians (if any), and your insurance company.
• Altering or forging of a prescription is a felony and will be reported by law to local law enforcement and the Drug Enforcement Agency.
• Selling, trading, or sharing of prescription medications is illegal and will be reported to law enforcement.
• Patients may be terminated from the practice with 30 days notice for noncompliance in taking of their medications and/or noncompliance with timely office visits for proper medication management and evaluation.

Patients can request refills by calling our office during business hours. When requesting a refill, please provide the following information:

1.Full Name 2.Date of Birth 3.Phone Number 4. Name, dosage and frequency of the medication(s) 5. Name & phone number of pharmacy

Patient agrees to take all medication exactly as instructed by physician(s). Patient is NOT allowed to change dosage amounts or alter the time schedule of taking the medication. Patient is aware that most of the manufactures of drugs used to treat chronic pain recommend against the operation of heavy equipment, which includes driving a motor vehicle.  Patient agrees to NOT combine any routine/scheduled/narotic medications with the consumption of alcohol.

I have reviewed the terms of this Prescription Policy and I agree to them.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED PURSUANT TO THE HEALTH INSURANCE PROBABILITY AND ACCOUNTABILITY ACT (HIPAA)

Our practice is dedicated to maintaining the privacy of your Individually Identifiable Health Information (IIHI In conducting our business, we utilize paper and electronic medical records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. We realize that these laws are complicated, and we want to provide you with the following important information.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. Additionally, this policy is available on our website alphamedicalonline.com under patient resources.

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice. We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object: required by law, public health reasons, communicable diseases, required by the FDA, abuse or neglect of a patient, workers’ compensation, national security, inmates under treatment.

You have the right to inspect and copy your protected health information. You must submit your request in writing to your physician in order to inspect or obtain a copy of your IIHI. As permitted by federal or state law, we charge you a reasonable copy fee for a copy of your records. You have the right to request a restriction of your protected health information and ask us not to disclose your information to certain individuals. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. You may have the right to have your physician amend your protected health information if you believe it is incomplete or inaccurate. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. All requests must be made in writing.

Authorization

I give my permission for Alpha Medical Clinic and its staff to leave any medical/lab information for me at the following phone numbers and email. You acknowledge that you have been advised of the risk of transmission of this information, understand that this is not a secure format, acknowledge that this information may be seen by a third unauthorized party and take full responsibility of the possible security breach.