Women: Are you.....
Information of Insurance Policy Holder
(if self, skip section)
In the last year visited:
FOR MALES ONLY:
FOR FEMALES ONLY:
By Signing here, I state that the above information has been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health.
Referral ProcessIt may be necessary for our office to refer you to a specialist to manage your care. In order for a referral to be made, you must be evaluated first in our office. If you need to request a referral from us, phone us at least one week prior to your appointment. As part of the referral process, we may need to share your medical information with another provider or specialist. Your privacy is protected as only minimal information is shared.
Medication RefillsPlease bring your medications to your appointments. Should you need refills prior to your next appointment, first call your pharmacy. They can request a refill from our office. Please give us at least 48 hour notice prior to your medication running out, 2 weeks notice if it’s a mail-order pharmacy. Pain medicines may require an appointment.
BillingPlease bring your insurance card(s) to each visit. All co-pays and deductibles are the patient’s responsibility and expected to be paid on the day of service prior to being evaluated by the provider.
If you have a high deductible plan without a copay, you are expected to pay $50 towards your services prior to being evaluated by a provider.
Scheduling AppointmentsPatients are seen by appointment only, except in the case of an emergency, which may cause delays. We ask for your understanding, knowing that if you ever require urgent care, we will give you prompt attention. To schedule appointments, please call (330) 422-4377. In the event that you are unable to keep your appointment time, please call at least 24 hours in advance to reschedule. There will be a $25 charge for no show appointments. If you miss 2 or more appointments due to a “no show” appointment, your chart will be reviewed and you may be discharged from this practice.
Hospital/EmergenciesBoth of our physicians have hospital privileges at Cleveland Clinic South Pointe Hospital. Dr. Aarondeep Deol also has hospital privileges at UH Portage Medical Center. If you have a life threatening illness, call 911 or go to the nearest Emergency Room and have a family member call our office.
After Hours/On Call PolicyOur office hours are Monday through Friday 9am-5pm. Please call the main office phone (330) 422-4377 if you need medical attention after hours that cannot wait until morning. If you have a non-urgent request, you can leave a message for staff to be returned the next business day. If it is an urgent request, you can use the Spruce app to contact the doctor. After speaking with you, you may be prescribed medication, advised to follow up in the office, or advised to pursue further urgent or emergent care.
UH Twinsburg Urgent Care - 8819 Commons Blvd., Suite 101, Twinsburg, Ohio 44087, P: 234-837-5418Cleveland Clinic Emergency Department - 8701 Darrow Rd, Twinsburg OH 44087, P:330-888-4176
By signing on the next page, I agree to the above policies.
Please read and sign at the bottom to agree to the following statements:
I hereby authorize the release of medical information to insurance carriers, referring providers, and healthcare systems concerning my illness and treatment, when necessary. I hereby assign to the doctor all payments for medical services rendered to me or my dependent. I understand I am responsible for any amount not covered by insurance.
Acknowledgement of TreatmentI request and authorize Dr. Aarondeep Deol, Dr. Nazmine Deol, staff, and resident physicians, to perform general treatments and procedures as may be deemed necessary in my care.
Notice of Privacy Practices AcknowledgementI, the undersigned, acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read, or have been offered a copy, and understand the notice (available upon request).
Medicare One Time Direction of PaymentsIf applicable, I give my permission to ask for Medicare payments for my medical care. I understand that Medicare needs information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment requests. I understand that the Health Care Financing Administration (HCFA) is the government Medicare agency