PATIENT INFORMATION SHEET

I certify that the above information is true and correct to the best of my knowledge. As the responsible party, I agree that all charges that are not directly paid by my insurance will be my responsibility.

WEIGHT LOSS HISTORY:

WEIGHT RELATED MEDICAL HISTORY (do you have or have you had any of the following illness or symptoms?)

Sleep difficulties

Have you ever had:

In our efforts to comply with the health information privacy act, HIPPA, we need to be certain that we guard your privacy according to your wishes when it comes to your family, friends and co-workers.

Please select your choice responses to the following questions:

You must inform us, in writing, of any changes in your directives. This record takes effect September 1, 2003 and will be kept in your file with your acknowledgment of receipt of our Notice of Privacy Practices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us, or to assist with, aid in, or facilitate the collection of data for purposes. Such information may be released to insurance companies, HMO’s and PPO’s, managed care organizations, IPA’s, Medicare/Medicaid, or other governmental or third party payers, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician that is directly or indirectly responsible for your medical care or the payment thereof.

This office will not use or disclose any of your medical and financial information for any purpose not stated above without your specific authorization. You may revoke your authorization at any time.

You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential communications of your protected health information. You have the right to inspect copy and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office.

We are legally obligated to maintain the privacy of your protected health information, to provide you with this Notice of Privacy Practices, and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to protected health information.

You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. This office will make no retaliation against you because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.

You may speak with the office Manager or Privacy Officer to obtain additional information regarding any questions you may have concerning this notice or to receive a printed copy of this notice. This Notice of Privacy Practices is effective as of April 14, 2003.

EFFECTIVE JULY 3, 2013

Thank you for choosing Weight Management Medical Associates as one of your healthcare providers. We are dedicated to providing the best possible care and service to you. Your clear understanding of our financial policy is important to our professional relationship. We make every effort to keep our fees reasonable while at the same time covering the cost of the services we provide.

FEES AND PAYMENTS:
Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable co-payments, co-insurances, and deductibles for participating insurance companies. We accept cash, personal checks (in-state only), VISA, Discover and MasterCard. There is a service charge of $25 for returned checks over and above what your financial institution charges. Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments.

REFUNDS:
Patient/guarantor credits in amounts less than $20.00 will be retained on account to be credited toward future balances unless a written request for refund is received. Amounts $20.00 and greater will automatically be refunded to the patient/guarantor.

INSURANCE:
We do not accept Medicare, Medicare Advantage, Medicaid, or managed care insurances that require a referral from your primary care provider. In order to address the needs of our patients without insurance and patients with coverage limitations, we charge reasonable office visit or self-pay fees. Please speak with our staff to obtain these costs.

It is the patient’s responsibility to know her/his insurance coverage benefits and present his/her card at each visit. Patients who have plans that we do participate with are expected to pay their co-payments, co-insurances, deductibles, or any non-covered services at the time of their visit. Patients who are not covered by insurance, on a plan that we do not participate with, or if we are not able to verify your coverage must pay at the time of service.

We bill insurance as a courtesy to you. If we have not received payment from your insurance company within 45 days of the date of service, you may be expected to pay the balance in full. You are expected to notify our office if your insurance coverage changes.

Not all services are a covered benefit in all policies, so it is very important that you understand the provisions of your individual policy. Insurance companies select certain services they will cover; therefore we cannot guarantee payment of all claims by your insurance company. You are responsible to be sure all charges are paid whether by you or by your insurance carrier. Your time of service receipt includes all information necessary for submitting claims to your insurance company.

If you need assistance or have questions, please contact our Billing Coordinator between 8:00 a.m. and 4:30 p.m., Monday through Friday at 972-303-8955, extension 101.

COLLECTION AGENCY FEES:
Should your account become severely delinquent, the patient or guarantor agrees to pay all costs of collection including collection fees, attorney fees, and contingent fees to collection agencies in addition to the amount owed.

EFFECTIVE JULY 3, 2013

MISSED APPOINTMENTS/LATE CANCELLATIONS:
We require 24-hour notice for cancelling any appointments. Please keep in mind that each missed or skipped appointment is not just time lost, but also time when other patients cannot be seen. Each missed appointment or cancelled appointment within 24 hours will be flagged. We reserve the right to charge your account a $25 fee for multiple missed or late-cancelled appointments.

We understand that circumstances occur that do not allow you to keep your scheduled appointment. If this is the case, please call and discuss this with the office staff as soon as possible. We will waive the cancellation fee for this appointment as long as you do not have a history of cancellations. Our schedule fills up quickly, and this will allow other patients to fill those slots.

MEDICATIONS:
Our office does not participate in prior authorization requests for medications. The prior authorization process prevents our medical staff from providing you with the best possible care. In most cases, insurance companies do not pay for weight loss medications, and our providers make every attempt to prescribe weight loss medications that are reasonable. If we prescribe other therapies for weight management or associated weight-related symptoms, including but not limited to Vitamin B12, diuretics (water pills), thyroid medication, testosterone, hCG, or sleep medication, we will not process prior authorization requests for those either.

MEDICAL RECORDS:
In order to be in compliance with Texas state law and HIPAA regulations, we charge a per page charge, payable in advance, if you would like a copy of your records sent to you or another physician. This per page fee policy is available upon request. As always, if a collaborating physician (primary care or specialist) requests portions of your record to assist in your care, there is no charge.

LAB CHARGES:
Depending on your insurance, you may get a separate bill from the lab facility that performs your lab work. These charges should be discussed directly with the lab facility.

ADVANCED HEALTHCARE PROVIDER (AHP):
A Nurse Practitioner is a registered nurse who has advanced education and clinical training in a health care specialty. Our Nurse Practitioners have national certification in their area of expertise. Dr. Garza works alongside two nurse practitioners. Nurse practitioners diagnose and manage common acute and stable chronic health problems. In addition to their traditional registered nursing skills, nurse practitioners can perform comprehensive physical examinations, order and interpret diagnostic tests, request specialty consultations, perform and prescribe therapeutic measures and furnish medications. A nurse practitioner may be involved with health promotion and disease prevention as well as patient and family education. It is your choice as a patient to decide which provider you would prefer to see, so should you have a preference please let the front desk staff know and they can schedule you with the appropriate provider.