New Patient Registration - Cash Pay

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Please fill in all blanks. If not applicable, please write N/A in that space. Thank you!

Guarantor Information

(Responsible Party and/or insurance subscriber) If same, put N/A.

How will you pay for this visit?

authorize this facility to examine and provide medical treatment. I assume full responsibility for any balance due. I authorize my insurance company to pay directly to this facility. I authorize this facility to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand it is my responsibility to know all rules and restrictions of my insurance policy, to know which hospital, emergency rooms, laboratories, x-ray department and specialist providers which are assigned to me according to my insurance policy rule. It is this facility's procedure to share Protected Health Information with labs, x-rays, consulting physicians and hospitals. We will call, fax or e-scribe the pharmacy of your choice regarding prescriptions. We will only exchange minimum necessary Protected Heath Information for each transaction.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

To Our Patients

As you know, if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held in your password protected file until your insurances have paid their portion and notified us of the amount of your share. At the time, any remaining balance owed by you will be charged to your credit card. and a copy of the charge will be either mailed or emailed to you.

This will be an advantage to you, since you will no longer have to mail us checks or call in to make payment over the phone. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. This combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment.

Copays due at the time of the visit will, of course, still be due at the time of the visit.

If you have any questions about this payment method, please do not hesitate to ask.

Sincerely yours,

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Disclosure of Medical/Financial Information to Friends or Family

(For Patients 18 years and older)

I, the undersigned, hereby authorize Dr. James R. Bond, Jr. and staff to disclose information from my medical or financial record to the following people.

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This authorization is given freely with the understanding that:

  1. This authorization is valid between January through December of year signed
  2. May revoked in writing at any time but not retroactively.
  3. The facility, its employees, officers, and physician are hereby release from any legal responsibility of liability for disclosure of the information I authorized previously.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Consent for Use and Disclosure Of Protected Health Information

With my consent, James R. Bond, Jr., M.D., P.A. may use and disclose protected health information (PHI) about me carry out treatment, payment, and healthcare operations (TPO). Please refer to James R. Bond, Jr., M.D., P.A.'s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have been provided with a copy of the Notice of Privacy Practices prior to signing this consent. James R. Bond, Jr., M.D., P.A. reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Marisela Acosta, Privacy Officer at 1615 Lancaster Drive, Suite 10, Grapevine, TX 76051.

With my consent, the officer of James R. Bond, Jr., M.D., P.A. may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory result among others,

With my consent, the office of James R. Bond, Jr., M.D., P.A. may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, the office of James R. Bond, Jr., M.D., P.A. may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder card and patient statements. I have the right to request that the office of James R. Bond, Jr., M.D., P.A. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to give the office of James R. Bond, Jr., M.D., P.A. use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extend that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, the office of James R. Bond, Jr., M.D., P.A.may decline to provide treatment to me.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form

Acknowledgement of receipt of Information Practices Notice ($164.520(a))

understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test result,diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility's Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

  • I have the right to review this facility's Notice of Privacy Practices prior to signing this acknowledgement;
  • This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

For Office Use Only

Marisela Acosta - Officer Manager HIPAA Officer

Medical History

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Please list your personal medical history here: Please do not list family history here:

Please list only the names of medication you are currently taking:

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Joint Replacement:

Other Surgeries not listed:

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Financial Policy

Fee for Service, Private or General Insurance

Thank you for choosing our practice. We want to make every experience you have with us a positive one. Over the past few years, the practice of medicine has become more complicated for physicians and patient alike.

Because of the growing complexity of the insurance business, we feel we can no longer assume that patients fully understand the relationship between the insurance company, the doctor and themselves. In an effort to clarify this relationship, we have developed a set of guidelines regarding financial responsibility. If you have any questions, please speak with the office staff, You will be asked to sing the end of the form.

Payment is expected at the time of service.

We will give you the necessary forms for submission to your insurance carrier for a partial reimbursement of fees incurred. The amount reimbursed by your carrier may be adjusted, according to your plan provisions.

Determining Our Charges

An office visit charge includes discussing your complaints with the doctor, your examination and assessment, and any treatment given by prescription. Many times patients are unaware that when procedures are performed in the office they are not necessarily included in the charge for the office visit. Procedure charges would include such things as performing a biopsy, removing or destroying a skin lesion, performing cosmetic procedures (see below), or drawing blood for a laboratory test. Please be aware that if a procedure is done during an office visit, this may add to the total cost of your visit. If you have any questions about our charges, please ask us before we perform a procedure. We do not generally discuss cost of procedures unless you ask.

If you have no insurance and feel like you cannot afford a procedure you need, please let us know. We will do whatever we can to help someone who needs care but has an inability to pay at the time services are rendered.

Please recognize that the practice of medicine is not an exact science and acknowledge that there are no guarantees or assurance concerning the result of procedures.

Not Medically Necessary or Cosmetic Procedures.

The following procedures are routinely considered not medically necessary or cosmetic. Your insurance carrier may not reimburse you for these services (including office visits for evaluation of these conditions):

  • Removal of benign lesions (moles, warts, skin tags, cherry or spider angiomas, lentigos or liver spots, cysts, milia and seborrheic keratoses)
  • Collagen treatments
  • Glycolic acid or other chemical peels
  • Ear Piercing
  • Scar Revision
  • Laser surgery for certain benign lesions
  • Cautery for treatment of dilated blood vessels on the face
  • Hair Loss
  • Vitiligo

Laboratory and Pathology Fees.

Many times it is necessary to obtain tissue or perform lab tests to confirm a diagnosis or to determine a course of treatment. If any tissue is removed for a pathology examination or if a laboratory test (blood work, culture, etc.) is done in our office, the actual testis usually carried out by someone else

THIS MEANS YOU WILL RECEIVE A SEPARATE BILL FROM ANOTHER DOCTOR OR LAB FOR THESE TESTS.

Forms of Payment

We accept cash, personal checks, Mastercard and Visa.

Estimation of Services

We will be happy to give you an estimate of fees when this is possible. Please remember that only the doctor can give you an accurate estimation of the cost of a procedure since he will determine the exact procedure to be performed. Please keep in mind that it is only an estimate of costs. Unforeseen circumstances could cause the actual cost of a procedure to increase when done at a later date. The only time we can assure you of the exact cost of a procedure is on the day of service when the doctor has determined the actual coding to be used. Also, please remember that the estimate of our charges will not include work done by any outside lab or pathology service.

Returned Checks

There is a fee of $40.00 for all returned checks.

Collection Efforts

We will send you FOUR statements regarding your balance. On the THIRD statement of 1.5% services charge will be added to your balance. If you should receive a FOURTH statement noted "FINAL" the account balance will be turned over to a collection agency. There will be a 35% service charge to any outstanding balance that is turned over to a collection agency. All fees charged are your responsibility.

By signing below, I am indicating that I do not have a government plan such as MEDICARE or MEDICAID or CHIPS or STAR.

I have read and understand the above completely and agree to comply with the financial policies of this office. I understand that my signature also allows this office to release information regarding my visits to my insurance carrier should they request additional information about a claim that I file.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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