MD One: Financial Responsibility/Office Policies

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.
Date *

Month Day Year
Date
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Patient E-Mail
example@example.com
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *
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Emergency Contact Relationship
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.
I understand that is is my responsibility to know my insurance benefits and whether or not the services rendered are covered benefits. I also understand that it is my responsibility to know referral requirements, and cost share information such as deductibles, coinsurances, and co-payments. If you are not familiar with your plan coverage, we recommend you contact your carrier directly. *
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I understand that the patient is responsible for notifying our office of any changes to demographics or insurance and billing information as soon as possible, at least 24 hours prior to the appointment. *
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I understand that if insurance coverage and benefits cannot be verified by our office prior to the appointment, the patient has the option of re-scheduling the appointment. If the patient decides to keep the set appointment and/or receive services, it is with the understanding that their health plan may not pay for charges related to the services provided by MD One Internal Medicine Associates, and the patient would be responsible for payment of all charges. *
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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.
Any non-covered services, as determined by the patient’s insurance carrier, are the financial responsibility of the patient. Finance charges are accrued monthly on unpaid balances and are the responsibility of the patient. *
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Prior to providing services, payment of prior outstanding accounts will be requested and should be received. Patients with unpaid delinquent accounts or accounts which have been written off to bad debt may be denied treatment if not medically urgent. *
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Delinquent/Unpaid Account
Prior to providing services, payment of prior outstanding accounts will be requested and should be received. Patients with unpaid delinquent accounts or accounts which have been written off to bad debt may be denied treatment if not medically urgent. Accounts which cannot be collected by the physician after normal inhouse collection procedures may be referred to a collection agency, magistrate, or attorney for further collection action in accordance with the physician’s established guidelines. Changes shown by statements are agreed to be correct and reasonable unless protested in writing within (30) thirty days of billing. Refunds: Overpayments will be refunded to the appropriate party, normally the insurance company or guarantor. Patients’ refunds will not be processed until all active or past due accounts are paid in full. *
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No Show / Same Day Cancellation Policy

Our staff works hard to offer you an appointment that is convenient for you. We understand that there are times when you must miss an appointment due to emergencies or other obligations. If circumstances prevent you from keeping your appointment, please call the office at least 24 hours in advance to reschedule. If a patient fails to cancel his/her office appointment at least 24 hours in advance, the patient is responsible for $25 fee which will not be applied to any copay, deductible or coinsurance; this fee will not be covered by your insurance company. Please understand that our policy is in place to assure that we maintain a superior standard of care for all of our patients. Additionally, missed appointments prevent us from caring for other patients that may need our services at that time.
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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.
I have read, fully understand, and agree to the above policies, financial responsibility statement, payment guidelines, consent for treatment/release of medical information & insurance authorization. I also certify that all of the information, provided is complete and accurate. *

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Photo of Front of Insurance Card
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Should be Empty:

MD One: Financial/Office Policies

Health Insurance Policies

Financial and Payment Guidelines

Delinquent/Unpaid Account

No Show / Same Day Cancellation Policy

Document Fees: Insurance/Disability Forms

Document Fees: Medical Record Requests

Lab/ Radiology / Diagnostic Services

Medication Refills

CONSENT FOR TREATMENT, RELEASE OF INFORMATION, AUTHORIZATION & ASSIGNMENT OF BENEFITS