New Patient Registration HMO Agreement

Please correct the errors described below.

Due to the rising cost of providing healthcare we are introducing our policies. Many manage care and other insurance companies require that we collect co-pays, deductibles and co-insurance from patients, not only is this the arrangement in your contract with your insurance, but it will save time, money and confusion in the long run.

"HMO" Health maintenance organizations members cannot see a specialist without a referral from your primary Care, Family or Internal Medicine doctor. It is the Patient's responsibility to obtain a PCP-HMO Referral, if you do not have a valid referral you may be seen, but the visit must be on a cash basis.

To avoid an unnecessary bill to you please present your insurance card at each visit to the front desk representative.

Un-insured Patients, payment will be collected at the time of check in.

Office visit Co-Pays, Co-insurance and or Deductibles are due prior to rendering services at the check in window. Payment arrangements must be made prior to your appointment. Balances due on your account will be collected in advance before seeing the doctor.

Missed/No Show appointments and /or failure to cancel your appointment within 48 hours will result in a $40.00 fee. Stress Echo or any test scheduled, missed fee $75.00.

Prescription Refills require 5 business days advance notification. Please ensure you have enough medication before you run out. Call your Pharmacy and have them fax the request to our office

Mail in Prescriptions require 10 days advance notice.

Medical Records fee is $35.00 please allow 5 business days to process your request.

We do not accept Secure Horizon - NTSP Group plan.

It is your responsibility to notify our office of any changes in your personal information: address, phone number, or insurance prior to your appointment.

We accept Cash, Checks, Money Orders, Debit Cards, Visa, MasterCard, Discover, Amex. $35.00 on all returned checks.

DISCLAIMER: 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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