New Patient Forms

Our office is pleased to have the opportunity to serve you. Our primary mission is to provide you with quality, cost-effective medical care. Together, we (patients and your healthcare team) are trying to adapt to the changing ways that healthcare is financed and delivered. The following guidelines were developed to help you through the process.

Payment Guidelines:

• We collect co-payments, co-insurance, and/or deductibles at the time of service unless other written arrangements have been made in advance with our office.
• We accept Cash, Checks, Money Orders, and Credit Cards (Visa, Mastercard, American Express, and Discover) and Venmo.
• If your check is returned, a processing fee of $30 will be assessed in addition to the amount of the check.
• A claim will be sent to your insurance company for payment. If your insurance company remits the payment to you, please send the payment to our office, along with the Explanation of Benefits.
• Any balance that your insurance company determines to be your financial responsibility will be billed to you. Payment is due in full upon receipt of your statement. Balances that remain unpaid after 90 days may be referred to an outside collection agency for further collection efforts.

 

No Show / Late Cancellations:

To provide the best possible service and availability to all patients, our practice has implemented the following fees:

• Office visit – We require 1 business days’ notice for all office visit cancellations. If the required notice is not given, a $50.00 charge may be assessed to the patient account.
• Procedure – We require a 3-business day notice for all procedure cancellations. If the required notice is not given, a $100.00 charge may be assessed to the patient account. The missed appointment payment may be required prior to, or upon the next scheduled procedure or office visit.

 

Ancillary Services:

• Your physician may refer you to one or more “ancillary services” in connection with your medical care. An ancillary service is a service supplementing or supporting your medical treatment. The following are considered, but not limited to, possible
  ancillary services:
  • Ambulatory Surgery Center
  • Infusion Therapy
  • Laboratory & Pathology Testing
  • Nutritional Services
  • Pharmacy Services
  • Radiology/Imaging

• Your physician may have an economic interest in or business relationship with the company or person who provides the ancillary service(s). You are not obligated to use the provider that your physician refers you to. You are free to use any provider you choose.

 

When to present your insurance card:

Please present your insurance card at EACH VISIT. Specifically bring to our attention any changes (new card, new subscriber, or group number, etc.) since your last visit. This protects you from paying a bill due to providing incorrect information. There is a narrow window (30-45 days) to present an accurate claim to the correct insurance company. Failure to do so could mean the claim may be denied. If you have secondary insurance, it will be filed as a courtesy. However, if we have not received payment from your secondary insurance in a timely manner, the balance will become your responsibility.

 

Assignment of Benefits:

GastroMedConnect may file a claim for services rendered by the physician, facility, pathologist and or anesthesia provider. GastroMedConnect is authorized to transfer any patient overpayment to one of these associated entities if applicable. I hereby authorize GastroMedConnect to:

• Release any information necessary to the insurance company regarding my illness and treatments.
• Process claims generated for my examination/treatment.
• Allow a photocopy of my signature to be used to process insurance claims for a period of a lifetime.
• Keep this order in effect until it is revoked by me in writing. We value you as a patient and we are eager to serve you! Our priority is to provide you with the best possible care.
• If you would like to contact our Central Business Office, you may do so at 512-254-8311.

I have read and understand the guidelines and financial obligations as stated above:

Consent for Medical Treatment
I, the undersigned, as the patient (or the patient’s duly authorized representative) do hereby voluntarily consent to and authorize medical care encompassing all diagnostic and therapeutic treatments considered necessary or advisable in the judgement of any physician, his assistants, or designees. All medical care and treatments will be discussed with me, by the physician prior to any proposed treatments, testing, or medical procedures being scheduled. I am aware that the practice of medicine and surgery is not an exact science. I acknowledge that no guarantees have been made to me as to the results of treatments or examinations performed.

Consent to Obtain External Prescription History
I understand GastroMedConnect utilizes electronic prescribing technology and participates with SureScripts. I understand that my prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years. Detailed prescription history provides your provider valuable information and improves accuracy in your medication list.

Electronic Communication
As a service to our patients, we provide courtesy appointment reminder calls and when possible, text messages. We also may place other important calls and send text messages using a prerecorded or automated message. 

Notice of Privacy Practices
This notice identifies how medical information about you may be used and disclosed, and how you can gain access to this information.

 

I understand that the duration of this authorization is indefinite unless otherwise revoked in writing.

I authorize GastroMedConnect to disclose or provide my protected health information to the following individual(s) who is authorized to act as my personal representative for the purposes of receiving all protected health information about myself. As my designated personal representative, he/she may exercise my right to inspect, copy, and request amendments to my protected health information. He/she may also consent or authorize the use or disclosure of my protected health information.

• You authorize the practice to disclose all your protected health information to your designated personal representative.
• This authorization will remain in effect until terminated by you, your personal representative or another individual(s) of legal entity authorized to do so by court order or law.
• As stated in our Notice of Privacy Practices, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager. This can be done in-person or by mailing a request to:

Your GastroMedConnect Provider’s Office
Attn: Privacy Manager

Re-disclosure: We have no control over the person(s) you have listed as your personal representative. Therefore, your protected health information disclosed under this authorization, will no longer be protected by requirements of the Privacy Rule and will no longer be the responsibility of this practice. Copies of signed authorizations are available upon request

Information may be released to: 
GastroMedConnect/ Dr. Adib
115 Kohlers crossing, suit 455
Kyle, Texas 78640
Phone: (512)-254-8311
Fax: (512)-254-8320
Direct Address:
gastromedconnect@directaddress.net