New Patient Registration - Commercial Insurance

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

Insurance Information

Guarantor Information

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

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 to 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

Managed Care (HMO, PPO, EPO, POS, Open Choice, Managed Choice)

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 patients 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. Please recognize that the practice of medicine is not an exact science and acknowledge that there are no guarantees or assurance concerning the results of procedures. You will be asked to sign at the end of the form.

We will file your insurance for you if we are on your network

You are required to see a Primary Care physician (PCP) under some plans in order to see a dermatologist or other specialist.

If your plan requires authorization by a PCP, you must obtain a referral letter or number prior to your visit.

If the referral is not obtained by the time of your visit, you may pay for the visit at the time of service and file the insurance yourself, or you may reschedule.

There are time limitations on referral and claims filing. The referral limitations are set by your PCP and must be followed by this office. You are responsible at each visit for assuring that we have a valid referral letter or number. Some plans require that a claim be filed within 60 days or will be denied for timely manner.

You must present your card and identification at the time of your office visit.

If we do not receive your insurance card before you see the doctor, that visit becomes fee for service and full payment is expected at that time.

Co-Payments, Deductibles and Co-Insurance

A co-payment is a set dollar amount you owe for each office visit. All PPO plans are subject to a deductible if a procedure is performed (office surgery, etc). You will be asked to pay your co-payment plus any procedure fee at the time of service if your deductible has not been met for the year. Co-insurance is the amount required by some insurance carriers over and above the deductible and co-payment amounts. Typically, a co-insurance percentage is required on procedures done in the office. You will be billed for this amount should your insurance company notify us that additional payment is due from you.

Not Medically Necessary or Cosmetic Procedures.

In order to keep health care costs down, all insurance companies now put restrictions on some previously covered procedures. Our office is aware of many of these not medically necessary or cosmetic procedures and will attempt to procedures. Our office is aware of many of these not medically necessary or cosmetic procedures and will attempt to alert you to these procedures when possible, If you and the doctor decide to continue with a procedure that falls into this category, we require payment in full at the time of service. There is no reduction in fees for managed care patients when cosmetic procedures are performed, and we will not file with your insurance carrier for these services.

The following procedures are routinely considered not medically necessary or cosmetic. Your insurance carrier may cover 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
  • All Forms of 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.

We will attempt to use a lab which files directly with your insurance carrier. Some plans do not specify a particular lab to use. it is also not uncommon for insurance carriers to change laboratory or pathology services several times in one year and not notify us immediately. Therefore, you are ultimately responsible for any bill you may receive from the laboratory or pathology service used. If you receive a bill from the lab, please contact that lab directly to resolve any billing concerns. If the lab will not file your claims for you directly, please attempt to file the claims yourself and pay the lab directly for the services.

Forms of Payment

For your convenience, we accept cash, personal checks, MasterCard, Visa and Discover.

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. My signature authorizes this office to file my claims and assigns to this office all rights, title and interest to my medical reimbursement benefits under my insurance policy. I understand that my signature allows this office to release information regarding my visits to my insurance carrier.
I understand that I am responsible for my bills in the event the insurance company denies any claims.

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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