• MD One: Financial/Office Policies

    Welcome to MD One! So that we may maintain the most up to date and accurate information on our patients, we will request that you review and update this form at least once a year.
  •  - -
    Pick a Date
  • Health Insurance Policies

    Notice: Our office does NOT file auto insurance claims for visits relating to motor vehicle accidents. I authorize direct payment of my insurance benefits to MD ONE INTERNAL MEDICINE ASSOCIATES for services rendered to myself or dependent. Insurance will be filed for services rendered. Any charges for services not covered by insurance may be the responsibility of the patient or his/her guardian. If your insurance carrier rejects, delays, withholds, denies payment of its portion or covers only a portion of treatment for more than 90 days from the date of service, both the insurance and patient portions of your account then become your responsibility.
  • Financial and Payment Guidelines

    We are committed to providing our patients with the highest quality care. We thank you for taking the time to read and understand our policies. Payment is due at the time of service. This includes all co­pays, deductibles and co­insurance.
  • Delinquent/Unpaid Account

  • Document Fees: Insurance/Disability Forms

    There will be a $25 handling fee to cover the administrative fee for writing a letter or filling out claims forms, such as insurance forms and disability forms (except Medicare patients). The fee is due once the form is completed, and the patient will be directly responsible for this fee.
  • Document Fees: Medical Record Requests

    Medical Record Requests: A reasonable fee of $25.00 shall be charged for the first twenty pages and $0.50 per page for every page thereafter. Requests will be completed within ten (10) business days. 
  • Lab/ Radiology / Diagnostic Services

    I understand that I may receive a separate bill if my medical care includes lab, radiology, or other diagnostic services. I further understand that I am financially responsible for any co­pays, deductibles and co­insurance due for these services if they are not reimbursed by my insurance.
  • Medication Refills

    Please contact your pharmacy for medication refills. Your pharmacy will electronically send us a medication refill request which the physician will review. Refill authorizations may require 48/­72 hours. Please allow sufficient time for us to process your refill request. 
  • CONSENT FOR TREATMENT, RELEASE OF INFORMATION, AUTHORIZATION & ASSIGNMENT OF BENEFITS

    I consent to treatment necessary to the care which has been discussed and directed by the provider. • I authorize the release of all medical records to specialists and/or consulting physicians if applicable to my care and condition. • I authorize any holder of medical or other information about me to release to the Social Security Administration, Health Care Financing Administration, its intermediaries, its carriers, or any other insurance carrier any information needed for this or any other related claim to be processed. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to me or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any party who may be responsible for paying for my treatment. • I further authorize and request that insurance payments be directed to MD ONE INTERNAL MEDICINE ASSOCIATES.
  • Clear
  • Should be Empty: