Stephen L. Smith, M.D. has opted out from participation in the Medicare and all other State and Federal Health Care Programs under Sec. 1128 of the Social Security Act. Dr. Smith has chosen to become a Private Contract Physician as allowed under the Medicare law which went in effect January 1, 1998.
The undersigned hereby agrees that by signing this contract he/she WILLNOT submit a claim for medical services rendered by this office to Medicare or other State and Federal Health Care Programs, even if such items and/or services would otherwise be covered by Medicare.
The undersigned further acknowledges that Medigap plans do not make payment for items/services furnished by Dr. Smith, and that other supplemental insurance plans may choose not to make payment for items/services furnished by Dr. Smith.
The undersigned also agrees to be fully responsible for payment of such items/services and that Dr. Smith is not obligated to follow Medicare guidelines for fees he may charge the beneficiary for the items/services furnished.
The undersigned acknowledges that no reimbursement will be provided by Medicare for any and all services provide by Dr. Smith.
The undersigned further acknowledges that at this date and time, the beneficiary is not facing an emergency or urgent health care situation.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
We keep a record of healthcare services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record get more information about it by contacting the
NWHC Privacy Office at:
NW Integrative Medicine
Stephen Smith, MD
1029 N Kellogg St
Kennewick, WA 99336
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.
By my signature below, I acknowledge receipt of the Notice of Privacy Practices.
I authorize Northwest Integrative Medicine (NWIM) to discuss my medical information with the following individuals (Print all names listed below):
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Dr. Smith requires all patients to have a PCP (primary care provider) or specialist they have seen within the last 12 months receive copies of your medical records.
The following is a statement of our Financial Policy. We ask that you please read it and initial prior to any health care treatment.
Thank you for choosing us as your medical provider. We are committed to your health care.
We are NOT a Medicare or Medicaid provider; Dr. Smith has opted out of their plans. At this time we are not contracted under any insurance providers. We will be happy to bill your primary insurance as a courtesy (except for cash discounted services), but we are considered out-of-network. You will be responsible for any balance remaining after insurance processing, including but not limited to appointments not covered by your carrier, copays, coinsurance and deductibles. We cannot bill your insurance company unless provided the necessary information.
Please be aware some of the services and treatments we offer may not be billable to your insurance as they may not be considered reasonable or necessary by your insurance carrier.
Our staff tries to provide reminder calls the day before your appointment. Cancellations must be noted 24-hours before your scheduled appointment. Unless your appointment is cancelled within the required time, you will be charged a SSO missed appointment fee.
All charges for supplements are due in full on the day of your appointment or at the time of purchase. We research supplements to find the highest quality available on the market and offer them at a reasonable price. We provide this service to help you on the road to good health and to save you time finding them on your own. However, if at any time within 30 days, you desire to return a supplement, you may do so as long as it has not been opened.
Thank you for reviewing our Financial Policy Form. Please let us know if you have any questions or concerns.
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