By signing below, you are confirming that the Medical History information you have provided is accurate and a complete representation of your medical conditions, treatment, and history.
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We require a scanned or photo copy of a valid ID, and BOTH SIDES of ALL insurance cards to proceed.
Practice Policies, Consents, and Other Information
Adler Family Practice Payment Policy
1. Insurance. We participate in most insurance plans. If you are not insured payment is due in prior to services being rendered. If you are insured, but don’t have current proof of insurance (a current insurance card), payment is also due in full prior to services being rendered. Knowing your insurance benefit coverage is your responsibility, for our provided services, and those we order for you. Please contact your insurance company directly with questions regarding your coverage, we’re unable to answer coverage questions due to frequent changes and numerous variations in insurance coverage and plans.
2. Co-payments and deductibles. All co-payments and deductibles must be paid prior to services being rendered, there are no exceptions.
3. Non-covered services. Please be aware that some or all of the services you receive from us may not be covered or may not be considered reasonable or necessary by your insurance plan. You are personally responsible for the costa of these services by us or outside entities.
4. Proof of insurance. We are required to keep a copy of a your valid identification and valid proof of insurance on file at all times. If you fail to provide us with correct and updated insurance or personal contact information, you may be responsible for costs incurred as a result of incorrect or outdated information.
5. Claims submission. We will submit your claims and assist you as possible to help get our claims paid through your insurance. 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. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
6. Coverage or information changes. If your insurance or personal information changes, please let us know as soon as possible so we can update your information to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. It is your responsibility to update your name, address, phone, employment, insurance, or other relevant information changes as they occur.
7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. This may result in discharge from our practice.
8. Missed appointments. There is a $50 charge for all appointments that are missed without cancelling one business day prior to the appointment. (Ex: Monday appointments need to be cancelled by the previous Friday). If two appointments are missed without being cancelled within 12 months, you may be discharged from our practice. New patients who miss any of their first 3 appointments with us will be subject to discharge from our practice. Medicaid and Centennial insurance patients: Your signature below is your consent to assume this charge.
9. Unpaid Balances. Balances less than $200 must be paid before additional services will be rendered by our clinic. Balances of $200-$500 may be paid off over 2 months when a payment plan is arranged in advance with our administrative staff. All other AFP payment policies apply.
10. Document Fees. There is a minimum $40 document fee for all documents requiring medical signatures (FMLA, leave, etc). This excludes simple return to work notes.
11. Returned Checks. There is a $45 charge for all returned checks.
12. Payment Responsibility. I understand that the insured party is financially responsible for any balance not covered by insurance, including co-pay, out of network charges, and tests, orders and referrals excluded by my policy for any reason. I also understand the insured will be responsible for all charges incurred should there be no coverage on the date of service. I hereby authorize release of medical information necessary to file a claim with my insurance.
Miscellaneous Consents and Other Policies
1. Provider Communications and Access. The AFP Patient Portal provided to you provides staff and provider messaging, appointment requests, and bill payment functions, as well as others. Otherwise, access to our providers outside of appointments is limited. These items, among others, require an appointment with your provider: - Require a new or modified prescription, - Have a new or changing condition, illness or symptom, - Require a referral or medical order, - Have documents that require signature or review, - To review completed orders or test results. - Any type of “consult” with your provider.
2. Test Results. Test results including, CTs, Xrays, Blood Tests, and others, fall into two categories: Medically Concerning or Medically Unconcerning. Test results may be slightly abnormal, yet still be unconcerning as related to your care or condition. Most test results will be available to you on your Patient Portal. You will be notified by email when information is received from us on your Portal. If your results are Medically Concerning, and if a follow up appointment isn’t already scheduled, we will contact you to schedule an appointment to review your results with you.
3. Medication Refill Requests. Please contact your pharmacy first to send us an electronic refill request.
4. “Good Fit” Policy. As a private practice, we reserve the right to decline entrance into our practice, or to continue to manage patients that are inappropriate with staff, providers, or the business in general including Internet and Social Media. Inappropriate communication, behavior, or actions with staff are never tolerated, and will result in termination from our practice panel.
5. Home Care. We are unable to provide, or continue to provide, care for patients that become home-bound for any reason. Once the transition to home-bound care begins, we will assist in securing placement with an appropriate group or provider.
6. Treatment Non-Compliance. If there is a failure to follow treatment plans, diagnostic testing, or referrals to outside providers for conditions that are either not fully diagnosed and could pose a danger to the health of a patient, or are known to be dangerous to the patients health, due to willful non-compliance, that patient will be discharged from our practice.
7. Controlled Substance Prescribing. We no longer provide monthly (chronic use) controlled substance prescriptions for opioids, benzodiazepine (Ativan, Xanax, etc), or hypnotic (Ambien, Lunesta, etc) medications. Some of these drugs may be provided for acute issues on a short-term basis. If you are a new patient requiring these medications, a referral to an outside prescriber (Pain, Psychiatry, etc.) can be provided.
8. Cannabis Cards. We provide cannabis cards for qualifying conditions (see the NM DOH Cannabis Application for a list of these conditions). For patients currently in cancer treatment, a Cannabis Application can be completed for free, otherwise there is a $100 charge for a new card application, and a $75 charge for application renewals. Documentation of your condition is required, and for psychiatric complaints, a letter from a NM Licensed Psychiatric provider confirming the diagnosis is required.
Consent to Treat I consent to evaluation, diagnostic procedures, testing, and treatment as directed my Adler Family Practice Provider or his/her designee. I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care. I understand that this Consent to Treat will be valid for each visit I make to Adler Family Practice until revoked by me in writing.
Consent to Release InformationI acknowledge that Adler Family Practice may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Adlers Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Adler Family Practice. I acknowledge and consent to allow Adler Family Practice to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may “opt out” and not have my protected health information disclosed through health information exchange systems by providing the signed Adler “opt-out” form to the practice location where I receive treatment. Consent to Photograph/Digital Imaging I consent to photographs/digital images for treatment, and to verify identity for payment purposes. I understand that the Adler Family Practice will retain the ownership rights to these photographs/digital images, but that I will be allowed access to view them or obtain copies.
AFP Privacy Practices
When we contact you to schedule initial appointment, please request a paper or electronic copy of this document.
Telemedicine (Video Appointment) Consent
What is telehealth?Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.You can talk to your provider from any place, including your home. You don’t come into our clinic. Please note: Telehealth visits are not appropriate for all patients, or for all medical concerns. You provider will let you know if an in clinic appointment will be required.
How do I use telehealth?You talk to your provider by phone, computer, or tablet.You and your provider can see each other.
How does telehealth help me?You don’t have to go to a clinic to see your provider.You won’t risk getting sick from other people.
Can telehealth be bad for me?You and your provider won’t be in the same room, so it may feel different than an office visit.Your provider may make a mistake because they cannot examine you as closely as at an office visit. (We don’t know if mistakes are more common with telehealth visits.)Your provider may decide you still need an office visit.Technical problems may interrupt or stop your visit before you are done.
Will my telehealth visit be private?We will not record visits with your provider.If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.Your provider will tell you if someone else from their office can hear or see you.We use telehealth technology that is designed to protect your privacy.If you use the Internet for telehealth, use a network that is private and secure. There is a very small chance that someone could use technology to hear or see your telehealth visit.
What if I want an office visit, not a telehealth visit?For now, almost all visits are by telehealth. You cannot schedule an office visit now, unless it is approved beforehand by AFP providers, usually due to medical necessity or technical problems.You must wait until the office opens for all other appointments. We do not know when that will be.
What if I try telehealth and don’t like it?You can stop using telehealth any time, even during a telehealth visit.You can still get an office visit if you no longer want a telehealth visit. But until the office opens for all appointments, you will get an office visit only for one of the reasons listed above. If you decide you do not want to use telehealth again let your AFP provider or staff that you would like in-clinic appointments going forward.
How much does a telehealth visit cost? What you pay depends on your insurance.A telehealth visit will not cost any more than an office visit.If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.
Do I have to sign this document?No. Only sign this document if you want to use telehealth.
What does it mean if I sign this document? If you sign this document, you agree that:You've reviewed the information in this document.You can have your questions about telehealth answered by AFP staff or providers prior to your first telehealth appointment.You want a telehealth visit.