Payment is due at time services are rendered.
By signing below, you agree to and understand the following practice policies:
Consent for Medical Treatment
1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Adler Family Practice, its clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be
made as to the results of the treatments or examinations at Adler Family Practice.
2. I consent to the use and disclosure of my/the patient's protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the Adler Family Practice Notice of Privacy Practices.
3. I authorize payment of medical benefits to Adler Family Practice providers or their designee for services rendered.
4. I give permission to obtain all my medication/prescription history when using an electronic system to processprescriptions for my medical treatment.
By supplying my phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, missed appointment, overdue wellness visit, or any other reasonable healthcare related communication. I consent for AFP providers to request pharmacy, medication, and outside medical history information as available to them.
Testing and Results
I understand the clinic will use Tricore Laboratories. If I or my insurance company prefers another lab, it is my responsibility to inform a medical staff member before the specimen is collected so I am not billed for out of network labs. I understand it may take up to 7 days to get lab results and 3 days to get imaging results once the tests are done, and that if my test results that are considered to be within acceptable limits, they will be provided to me on my AFP Patient Portal when resulted and that I will not be notified by phone or regular mail.
Contacting your Provider and medical signatures:
Due to our small size, we are unable to provide phone consults except in rare cases, and only as determined neccessary by our providers. I understand an appointment is required to review test results, for all new or changing medical conditions or symptoms, for new prescriptions, or if my AFP provider hasn't previously prescribed them for me. We provide provider messaging through our Patient Portal, and believe this is the best and most efficient way to communicate with your provider.
ALL forms requiring provider signatures are subject to a $40 document fee, including FMLA, disability, and all other forms except for sick notes/return to work notes. The sick notes/return to work notes require that you were seen at an appointment with your provider for the illness/condition that caused the missed time. We cannot provide sick/return to work notes for illnesses we did not treat!
Missed Appointments and Late Cancellations (PLEASE READ!):
Due to our the small size of our clinic, we must operate at peak efficiency to remain viable in the increasingly complicated business of medicine. Missed appointments greatly impact our success, therefore we take missed appointments very seriously. Any appointment cancelled with less than one business day notice (Monday appointments need to be cancelled Friday, etc), will result in a $50 Missed Appointment charge. Insurance is not responsible for these charges, and it will have to be paid to schedule another appointment with our clinic. This includes Medicare/Medicaid patients. New patients will be discharged from our practice if they miss any of their first three appointments, and reserve the right to discharge patients for any missed appointments.
Discharge from Practice
AFP Providers reserve the right to discharge persons from the practice, typically for poor therapeutic relationship, non-compliance with treatment plans that increase a patients health risk (stopping diabetes medications for example...), non-payment of fees, appointment attendance issues, bad faith (lying, manipulative behavior, etc), or other aberrant clinical or business problems.