New Patient Intake Forms

I authorize Dr. Monika Saeedian (Saeedian Medical, Inc. dba Sinai Allergy) to use and disclose my protected health information (PHI). Note: Uses and disclosure for Treatment Records, Payment Information, and Healthcare Operations may be permitted without prior consent in an emergency. 

This authorization for release of information covers the period of healthcare from all past, present, and future periods. 

This PHI may be used for medical treatment or consultation, billing or claims payment, or other purposes deemed necessary by Dr. Saeedian.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Saeedian Medical, Inc. for services rendered to me. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine benefits payable for services rendered. I understand my signature requests that payment be made and authorizes release of medical information necessary for processing and reimbursement of claims. If another health insurance provider is listed as a Secondary Insurance (Item #9 of the HCFA 1500 claim form), my signature likewise authorizes release of the information to the insurer shown. Saeedian Medical, Inc. accepts the charge determination of Medicare, and I am financially responsible for coinsurance, deductibles and non-covered services.

OTHER INSURANCE: I request that payment of authorized benefits be made on my behalf to Saeedian Medical, Inc. for services rendered to me. I authorize any holder of medical information about me to release to my insurance provider any information needed to determine benefits payable for services rendered. I understand my signature requests that payment be made and authorizes release of medical information necessary for the processing and reimbursement of
claims.

FINANCIAL AGREEMENT: I agree that in return for the services provided by Saeedian Medical, Inc. I will pay my account at the time service is rendered or will make arrangements to honor my financial obligations that are satisfactory to the practice. Most insurance companies require the beneficiary to pay co-payments and deductibles at the time of service without exception. I recognize that it is not in the power of Saeedian Medical, Inc. to waive beneficiary co-payments and deductible balances. I understand that I am primarily responsible for the payment of any services not covered by my insurance.

Insurance:

As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.

 

Financial Arrangements:

Because we realize that every person’s financial situation is different, we provide a variety of payment options. For your convenience, we accept all major credit cards and checks. (returned checks will be subject to a $35 returned check fee). If the check is returned for any reason, you will have 7 days to contact our office and arrange another form of payment.

 

 

Patient/Parent/Guardian Responsibility:

• I understand that whoever accompanies my child to their appointment has authorization to consent to medical care as needed, and is responsible for payment of medical services.
• I acknowledge my responsibility for payment of all services provided by Dr. Saeedian in accordance with the practice’s fees and terms.
• In the cases where a parenting plan exists, the parent that brings the child in for the appointment is considered the guarantor and is responsible for payment.
• At the initial visit you may sign our consent for minor treatment form that allows us to render care at follow up visits without the presence of a parent or guardian.

 

Late Fees:

I understand that my account becomes delinquent if not paid within 30 days after billing and the unpaid balance becomes subject to a monthly finance charge of 1.5% (18% APR) or $35, whichever is greater. Any further delinquency will warrant the balance and any administrative fees being assigned to a collection agency.

 

Assignment and Release:

I authorize payment to be made directly to Saeedian Medical Inc. by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.

  

Credit Card on File Policy

Saeedian Medical Inc. is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office at the time you check in.  Credit cards on file will be used to pay copays when you are seen in our office, including account balances, after your insurance processes your claim.

We will charge your card on file any copay amount you may have right before or after your visit. After insurance processing, we will email you a statement and notify you of any remaining balance owed by you and confirm that we will be charging your credit card.  This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down. This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

If we do not receive payment for the amount listed on your statement within 13 days, we will run the credit card on file for the full amount owed. If your payment is declined, we will call you.  If our reminder call is not returned within one week, a $35 declined payment fee will be applied and another statement will be emailed. Your account becomes delinquent if not paid within 30 days after the date of the original statement.  The unpaid balance will be subject to a finance charge of 1.5% (18% APR) or $35, whichever is greater. Further delinquency will be subject to collections with additional finance fees.

I give Saeedian Medical Inc. permission to charge my credit card for any patient balance due on my account. If I have insurance coverage, my card will be charged AFTER my insurance has paid their portion.

 

HIPAA/Patient Consent Policy

Notice of Privacy Practices Written Agreement:

I have read a copy of Saeedian Medical Inc.’s Notice of Privacy Practices. I understand a written copy will be provided to me at any time upon my request. I understand Saeedian Medical Inc. has a link to the Notice of Privacy Practices on the practice website located at www.sinaiallergy.com.