Welcome to RheumWell!

We are delighted that you are considering us for your healthcare needs. To help us provide you with the best possible care, we have created a new patient intake form that gathers important medical and demographic information.

Our online intake form is comprehensive and may take some time to complete. Your effort are greatly appreciated. Tailoring our care to meet your specific needs is essential, and we depend on the detailed information you provide us about your medical history and current symptoms to do so.

When completing the form, please make sure to have your insurance card handy, as you will need to provide information from it. This will enable us to verify your coverage and ensure that you receive the maximum benefits available to you.

We understand that your time is valuable, and we have made every effort to keep the form as efficient as possible. Please allow at least 15 minutes to complete it. Your cooperation in filling out the form before your appointment will help us expedite the intake process and minimize unnecessary delays, allowing us to focus more on your care during your visit.

Our scheduling department will review the information you submit and contact you shortly to schedule your appointment. 

Thank you for considering RheumWell as your healthcare provider. We look forward to welcoming you as a patient and providing you with exceptional care.

Best regards,
RheumWell Team

Your health information privacy is important to us. We will not disclose your information unless you tell us to or the law requires us to do so. HIPAA requires us to provide you with our Notice of Privacy Practices and for you to acknowledge its receipt. The notice explains how we may use and disclose your health information, your rights, and how to exercise them. We may update the notice, and a current copy can be found on our website or by contacting our Privacy Officer. 

Please note that filling out this form does not create a patient-physician relationship until a physician has had the opportunity to conference with you, examine you in person, or through telehealth.

In the event of an emergency condition, please do not use this form or wait for a response. Instead, we recommend that you go directly to your local hospital or dial 911 for emergency services.

Please acknowledge receipt of the notice by checking the box below and clicking "Next".

To support clear communication and avoid misunderstandings between our patients and practice, we have established the following financial responsibilities. We're committed to providing you with the best possible care and believe your understanding of your financial responsibilities is a vital part of your care and treatment. If you have any questions about these responsibilities, please discuss them with our office manager.

Your Payment at Time of Service: Full payment, including co-payments, deductibles, and fees for services not covered by insurance, is due at the time of service. This helps us keep our financial operations smooth so we can focus on providing healthcare. We accept cash, checks, or credit cards for your convenience.

Working with Your Insurance: We have agreements with many insurance providers, which means we'll bill them directly for your treatment. If your insurance plan requires you to pay a portion of the costs, we'll collect this amount at the time of service.

Services Not Covered by Insurance: If your health plan determines a service is "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office, which we will send promptly to keep you informed. We encourage you to consult with your insurance company if you are unsure whether a specific service is covered.

Referral Responsibility: If your insurance requires a referral, it is your responsibility to obtain it from your primary care physician (PCP) and to provide the referral to our office prior to seeing the physician. This is to ensure that your insurance company will cover the service you receive. If you are unable to provide the referral prior to the visit, you will be responsible for the full cost of the visit.

Medicare Patients: If you have Medicare, PART B only, you are responsible for your Medicare deductible and your 20% of the charges at the time of service. This policy aligns with Medicare's standard payment structure, which requires patients to cover part of their healthcare costs.

Delinquent Accounts: Accounts that are not paid within 30 days from the statement date will be referred to a third-party collection agency. Should your account be referred to a third-party collection agency, you agree to reimburse us the collection agency fees, which may be based on a percentage of the debt, and all costs, and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

Telephone Consultations: As per AMA CPT guidelines, we may charge for telephone consultations with our medical professionals that involve evaluating and managing your medical condition. This is because these calls involve the time and expertise of our medical professionals. We will bill your insurance for such calls, but if it is not covered by your plan, you may be responsible for the charges.

Appointment Cancellations: Appointments must be cancelled at least 48 business hours (Monday - Thursday) prior to the appointment date/time. If you cancel or miss your appointment without providing sufficient notice, a $75 fee will apply. This policy is in place out of respect for our providers and our other patients. Late cancellations can lead to an unused appointment slot that could have been offered to another patient in need of care. Please help us provide efficient medical care to all of our patients by adhering to this policy.

Third-Party Costs: If you require lab testing, x-ray, or other diagnostic services, you may receive separate bills from those entities. This is because these services are often provided by separate specialists who require separate payment.

Self-Pay Patients: If you don't have insurance, have an insurance plan we don't participate with, or choose not to use your insurance, you're required to pay for medical services before they're rendered.

Policy Updates: Please note that this policy is subject to change. We encourage you to review it periodically to stay informed about any updates. Current policy is available on our website and at the front desk. Any changes to the financial policy will be posted in the office and on our website. Your continued use of our services following any policy changes constitutes your acceptance of the new terms.

Policy Acceptance: By receiving treatment at our practice, you acknowledge that you have read, understand, and agree to this financial policy. I also understand that this policy applies and extends to all future visits with all AARA RheumWell providers.

Digital Consent: You acknowledge that checking a box or submitting the form serves the same legal purpose as a handwritten signature.

By checking the box below, I {patientsName} acknowledge that I have read and understand the financial policy of AARA RheumWell and agree to the terms outlined above. I also understand that this policy applies and extends to all future visits with all AARA RheumWell providers.

This document outlines your rights and responsibilities regarding your care at our practice, covering aspects such as insurance information, assignment of benefits, and consent to treatment. We urge you to familiarize yourself with its contents to ensure clear understanding and smooth coordination of your healthcare services. 

Insurance Information Verification: I hereby certify that the insurance information I have provided is accurate, complete, and current, and that I have no other insurance coverage.

Assignment of Benefits: I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider of any services or care furnished to me by that provider or care center staff.

Authorization for Appeal: I authorize my provider to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided.

Forwarding Insurance Payments: If my health insurance plan does not pay my provider directly, I agree to forward to my provider all health insurance payments which I receive for the services or care rendered by my provider and its care center staff.

Release of Information to Insurance Plan: I authorize my provider or any holder of my medical information to release to my health insurance plan such information needed to determine these benefits or the benefits payable for related services.

Consent to Treatment: I hereby voluntarily consent to the rendering of such care and treatment as my providers, in their professional judgment, deem necessary for my health and well-being. If I request or initiate a telehealth visit (a "virtual visit'), I hereby consent to participate in such telehealth visit and its recording and I understand I may terminate such visit at any time. My consent shall cover medical procedures, examinations and diagnostic testing. My consent shall also cover the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither my provider nor any of his or her staff have made any guarantee or promise as to the results that I will obtain.

Consent for Emergency Treatment: In the event of a medical emergency, I understand that the practice will provide necessary treatment before obtaining consent if it is not feasible to get it from me or my representative. In such cases, I hereby consent to receive any emergency medical treatment deemed necessary by my provider. This may include the administration of anesthetics, X-ray examinations, surgical operations, or other procedures that may be advised by my healthcare provider. I also understand that the practice will attempt to notify my emergency contact as soon as possible in such cases.

Consent to Communication: I understand and agree that my provider may contact me using automated calls, emails, and/or text messaging, as well as direct communication from live personnel. These communications may notify me of preventative care, test results, treatment recommendations, or any other communications from my provider. I understand that I may opt-out of receiving all such communications from my provider by notifying my provider's staff. I understand the risks associated with communication through email and text and consent to communication through these mediums.

Use of Personal Data and Research: I understand that my personal data will be used and protected as per the practice's privacy policy and relevant laws. This includes necessary administrative tasks and de-identified use for research and education. I retain rights to access, correct, and raise concerns about my data use. If my de-identified data is used for research or education, my identity will only be disclosed with separate consent, and I can refuse this use without affecting my care.

Sharing of Information with Other Providers: I understand and agree that my provider may share my medical information with other healthcare providers or facilities involved in my care. This can include specialists, labs, hospitals, or pharmacies. The sharing of this information is to ensure a coordinated and comprehensive approach to my care.

Audio and Video Recording: For security, quality assurance, and staff training purposes, I acknowledge and consent to the audio and video recording in various areas of the office. I understand that these areas do not include private areas where personal health information is discussed. I understand that any recordings are stored securely and accessed only by authorized personnel.

Understanding of HIPAA Rights: I understand that my provider's Privacy Notice, which explains my rights under the Health Insurance Portability and Accountability Act (HIPAA) and how my information can be used and disclosed, is available on my provider's website and that I may request a paper copy at my provider's reception desk.

Changes to the Terms and Fees: I acknowledge that the practice reserves the right to change the terms/fees without prior notice. I understand that the new notice will be available upon request and in the office.

Policy Acceptance: By receiving treatment at our practice, you acknowledge that you have read, understand, and agree to this Patient Consent and Acknowledgement form.

Digital Consent: You acknowledge that checking a box or submitting the form serves the same legal purpose as a handwritten signature.

By checking the box below, I {patientsName} acknowledge that I have read and understand the Patient Consent and Acknowledgement form of AARA RheumWell and agree to the terms outlined above. I understand that this form applies to all future visits with all AARA RheumWell providers.

Thank you for considering RheumWell as your healthcare provider. We appreciate the effort you put into filling out the intake form and providing us with the necessary information.

Our scheduling department will review the information you submit and contact you shortly to schedule your appointment.

We look forward to welcoming you as a patient and providing you with exceptional care.

If you have any questions in the meantime, please don't hesitate to reach out to us.