New Patient Packet

Rheumatology Solutions 8930 Fourwinds Drive, Suite #100 Windcrest, TX 78239 (210) 590-9596

Please correct the errors described below.

Thank you for choosing Rheumatology Solutions.

We look forward to seeing you on:

Please arrive 15 minutes prior to your scheduled appointment time.

If you have any questions, you may contact us at 210-590-9596, Ext. 1100 / Ext. 1101 / Ext. 1102.

If you need to cancel this appointment, please do so at least 48 hours before the appointment.

Thank You,

Rheumatology Solutions

AUTHORIZATION FOR RELEASE OF COPIES OF PROTECTED HEALTH INFORMATION

authorize the following health care provider and/or organization to disclose and/or use the following protected health information to the designated person and/or organization for the purpose(s) listed below.

(name of health care provider/organization)
(name of health care provider)

Address:

Rheumatology Solutions 8930 Fourwinds Dr, Ste 100, Windcrest, TX 78239

(facsimile number)

210-693-1521

(phone number)

210-590-9596

I understand the following:

  1. I may revoke the authorization at any time (except to the extent that disclosure has already occurred in reliance upon this authorization) by sending a written revocation to the health care provider/organization designated above.
  2. Any treatment, payment, or my enrollment in any health plan or my eligibility for benefits will not be affected if I do not sign this Authorization.
  3. Any information disclosed by this authorization to any person/organization not a health care provider or health plan covered by federal and state privacy regulations could be re-disclosed by the recipient and no longer protected by those regulations.
  4. I am entitled to receive a copy of this signed authorization.

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

PF-1300 Authorization for Use and Disclosure of Protected Health Information

Information to be Used or Disclosed

Information described above may be disclosed to:

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Expiration Date of Authorization

Unless revoked or terminated by the patient or patient’s personal representative.

Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to the Rheumatology Solutions. You should contact the Privacy Officer to terminate this authorization.

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

Patient Financial Policy

Thank you for choosing Rheumatology Solutions as your health care provider. We are committed to building a successful physician-patient relationship with you. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc).

Co-pays

All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with patient account representative. We accept cash, check, VISA, American Express, MasterCard or Discover. A service fee of $50 will be charged to your account for all returned checks.

Insurance Claims

Health insurance benefits are confusing. Most plans do not provide 100% coverage for medical bills. Each plan has its own set of rules, exclusions and benefit structures. It is your responsibility to be familiar with your insurance policy's requirements. If you are unsure of your coverage as it relates to services rendered at our office, you should call the customer service telephone number on your insurance card before receiving those services. Insurance is a contract between you and your insurance company. We will bill your insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information. Incomplete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

Participating Insurances

We accept most insurance plans for our patients. Please call our insurance verification department for more information. It is your responsibility to given all new insurance information to our staff before your appointment.

Referrals

If you have an HMO or POS plan with which we participate, you may need a referral from your Primary Care Physician (PCP) to see our Specialist. Check your insurance card or call your insurance carrier to determine if your plan requires you to have a referral to see a Specialist. We must have the referral in the office before you are seen by our Specialist. You will be asked to reschedule your appointment in the event that your referral is not here at the time of your appointment. For this reason, it is important that you make sure that your Primary Care Physician has sent the referral and that we have received it before you come in to the office. Another option is to bring the referral with you at the time of your appointment, but this must be coordinated in advance with our referral coordinator.

Self-pay Patients

Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. It is always the patient's responsibility to know if our office is participating with their plan. Self-pay new patients will be required to bring a flat fee of $300 at the initial appointment. Only cash or credit card will be accepted. For all subsequent visits, payment is due in full at time of service.

Missed Appointments

Rheumatology Solutions requires 48-hour notice of appointment cancellation. Appointments missed and are not previously canceled may be charged a "No Show" fee of $50 to established patients or $100 fee to New patients.

Returned Checks

Rheumatology Solutions will charge a service fee of $50 for a returned check which is payable by cash or credit card. This will be applied to your account in addition to the insufficient funds amount. You will be placed on a cash or credit only basis following any returned check.

Outstanding Balance Policy

It is our office policy that all past due accounts be sent 3 statements. If payment is not made on this account, a notice of collections will be sent asking you to contact our business office to pay your account in full or make payment arrangements. If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice.

In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs including attorney fees and court costs.

This financial policy helps the office provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to contact our Business Office Monday through Thursday, 8:30 am to 5:00 pm. Please call 210.590.9596.

Authorization to Release Information:

I authorize Rheumatology Solutions to release information to my healthcare insurer or the Center for Medicare and Medicaid Services (CMS), or any other entity necessary to determine benefits and process claims related to medical services that have been provided to me. An electronic copy of this authorization will be deemed as valid as the original. I allow a photocopy of my signature to be used to process insurance claims.

Assignment of Benefits:

I authorize payment of insurance benefits, including CMS benefits, for medical services provided to me directly to Rheumatology Solutions. An electronic copy of this authorization will be deemed as valid as the original. I understand that I am responsible for any amount not covered by my insurance.

Financial Responsibility:

I have read the Rheumatology Solutions Financial Policy and understand that I am responsible for all fees for medical services rendered to me by the physicians and staff of Rheumatology Solutions. Any fees deemed patient responsibility or are not covered by my insurance company will be due on the day of service or upon resolution of my insurance claim. Rheumatology Solutions reserves the right to request payment of these fees before my insurance company has completed the processing of my claim (s) or if my claims are denied. It is my responsibility to notify Rheumatology Solutions of any changes in my health care coverage before services are rendered. I understand that by signing this form that I am accepting financial responsibility as explained above for payment for medical services rendered to me. An electronic copy of this authorization will be deemed as valid as the original. A photocopy of this agreement is to be considered as valid as the original.

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

Office Calls Policy

Thank you for choosing Rheumatology Solutions as your health care provider. We are committed to providing you the best available medical care. We ask that all patients read and sign our office policies prior to seeing the physician.

Payment for service is due at the time services are rendered. We accept Cash, Check, Visa, MasterCard, and Discover.

MEDICATION REFILL POLICY

You should contact your pharmacy before contacting our office about medication refills. You may already have a current authorized refill, and most local pharmacies will contact our office if you do not have a refill. If you take a medication every day, you should ask your pharmacy for a refill at least five days before the medication runs out. If you have any problems getting refills, please call the office right away. Our office handles medication refills during normal working hours Monday through Thursday from 8 am to 3 pm. We will handle your request within 48 hours. Rheumatology Solutions have a policy of not calling in medications for conditions or complaints that they have not been treating. The afterhours paging service is reserved for emergency calls only. No routine refills on medications will be made over the weekend and Holidays.

*Some insurance plans require a referral from a PCP*. It is the patient's responsibility to obtain this referral in order to be seen by our doctors. If a valid referral is not obtained at the time of appointment, your appointment will be rescheduled.

NextMD

To save time and eliminate phone tag we have implemented a secured internet patient portal with NextMD as a way to communicate with our patients for any medical issues, billing, and/or any results. With NextMD you will be able to communicate directly with your physician on any matter you may have. This is the best way to communicate with our office; it is a faster and more convenient way to address any issues/concerns you may have. For medical emergencies, go to the emergency room. For urgent medical questions, please call our office. NextMD should not be used for urgent or emergent medical issues. This site is provided to you at no charge.

NextGen Patient Portal is designed with the patient in mind and the site is user-friendly to ensure quick and easy access with you and your provider.

You will be able to:

  • Access your health information
  • Request to reschedule your appointments
  • Fill out forms online
  • Request prescription refills
  • Request results and request referrals
  • Receive statements
  • Pay your bill

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

Your information will be encrypted.

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