New Patient Policy Paperwork

Dear Patient,

We look forward to seeing you in our office. Thank you for giving us the opportunity to care for your medical needs. In order for us to provide you with the best care possible, we must follow a few guidelines and goverment regulations

OfficeHours

• Monday - Thursday 9:00 AM - 5:00 PM
• Friday: 9:00 AM - 12:00 PM (Scheduled Appointment Only)
• IV Antibiotic Treatment - Appointments are scheduled by the nurse.

By law we are required to have a copy of your Insurance card(s) and Photo ID on file.

Medicare & Medicaid

Dr. Welton is a provider for Florida Medicare & Medicaid. Your secondary insurance will be filed as a courtesy. However, if your secondary insurance has not made a payment within 90 days of Medicare payment you will be responsible for any remaining balances.

Blue Cross/Blue Shield

Dr. Welton is a provider of BC/BC. Any copay or deductible will be due at the time of service.

United Health Care

Dr. Welton is a provider of UHC. Any copay or deductible will be due at the time of service.

Private Insurance

Dr. Welton requires payment at the time of service. Your insurance company will be billed in a timely manner for you to receive any reimbursement to which you are entitled.

Self Pay

Dr. Welton requires payment at the time of service. Any question regarding payment arrangements please see the office manager.

Collections

All Unpaid balances will be sent to an outside collection agency or small claims court, after all practice efforts have been exhausted. Any and all small claims and collection cost will be the patient's responsibility.

Return check fee

A fee of $25.00 will be charged to any patient account for a returned check.

Appointment

(NO CALL/NO SHOW) will result in a $25.00 fee charged to the patient account for a missed appointment.

Fee for completing forms

A fee of $35.00 will be charged to the patient at the time of services.

Medical Record Release & Authorization for Use or Disclosure of Protected Health Information

I authorize Dr. Laurie Welton and staff to disclose all pertinent Protected Health Information to healthcare providers involved my medical care and treatment. I understand that only Protected Health Information is information related to medical treatment and medical care and I understand that this information cannot be disclosed without my approval. Furthermore, I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by the law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or ordered pending or in effect that would prohibit, limit, or otherside restrict my ability to authorize the use or disclosure of this protected health information.

Parenteral Medication Therapy

Office hours are by appointment only (Monday-Thursday 9-5, Friday 12-5). Parenteral treatments are to be scheduled with the nurse on the day before treatment. We do make exceptions for emergency consults.

Billing for Parenteral Therapy

MEDICARE & MEDICAID PATIENTS

We are providers for the Florida Medicare & Medicaid Program. Your secondary insurance will be filed as a courtesy.

PRIVATE INSURANCE PATIENTS

Our office participates with most insurance companies. If we participate with your insurance company as a courtesy we will file. If we do not participate with our insurance company payment is required at time of service.. We will file in a timely manner for you to receive reimbursement.

NO SECONDARY INSURANCE PATIENTS

For those patients without a secondary insurance, you will be responsible for your portion of the bill.

SELF PAY PATIENTS

Payment is expected at time or service unless prior arrangement have been made

Patient's Consent

(for use and disclosure of protected health information to carry out treatment, payment, or health care operations)

I agree to allow Dr. Weltion to use or disclose protected health care information of the listed patient to carry out treatment, payment, or health care operation.

I have been informed of the Privacy Notice. The notice is a more complete description of the uses and disclosures of protected health information that may be made, and of my rights with respect with respect to protected health information.

1. I have received a copy of the privacy notice.
2. I understand that I have the right to review the notice before signing this consent.
3. I understand that the terms of the privacy notice may change, and that I have the right to request a revised copy of the notice.

I understand that I have the right to request a restriction on how protected health information is used or disclosed in order for Dr. Weltion to carry out treatment, payment and healthcare operations. Further, I understand that this request for restriction must be in writing and if the health care provider agrees to the restriction, the restriction is binding. However, the health care provider is not required to agree to a requested restriction. I also understand that the office my call my home to confirm information, and will mail statements to the address I have listed, which is part of the healthcare operations of Lauri Weltion, D.O.

Photograph Consent Form

I give consent to Laurie Weltion and her staff for any photography that may need to be obtained during my treatment. I understand this information will be kept in my chart.

I the undersigned agree to all the above, I also agree to be responsible for any charges incurred by me or not payable by my insurance company. I also agree to be responsible for any legal fees and/or court cost incurred as a result of my failure to pay for services rendered.

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.