PATIENT REGISTRATION FORM

Answer all your questions and bring with you the day of your appointment. Please bring insurance cards and photo ID to every appointment.

Today's Date:

Primary Doctor:

PATIENT INFORMATION

Patient’s last name:

First:

Middle:

Birth Date:

Address:

City:

State:

Zip:

Social Security no.:

Primary phone no.:

Cell phone no.:

Race:

Ethnicity:

Language:

Employer:

Work phone no.:

Patient Email:

Spouse:

Spouse phone no:

Spouse employer:

IN CASE OF EMERGENCY

Name:

Relationship to patient:

Primary phone no:

Cell phone no:

INSURANCE INFORMATION

All of the information is required to properly bill your insurance company. If you do not provide requested information, you will be financially responsible for your visit.

Primary insurance:

Relationship to patient:

Subcriber's Name:

Birth Date:

Subcriber's SSN:

Copay: $

*Your copay is due the day of your appointment* It is your responsibility to know your copay. If you do not know your co pay, $30.00 will be collected on day of service.

Secondary insurance:

Relationship to patient:

Subcriber's Name:

Birth Date:

Subcriber's SSN:

May we contact you with our automated appointment reminder system?

YES NO

May we leave medical information at your primary telephone number?

YES NO

AUTHORIZATION TO RELEASE INFORMATION AND PAY BENEFITS TO PHYSICIAN

I/We hereby assign all medical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plans to Leon W. Lewis MD, PC. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as the original. I understand that I am financially responsible for all charges for services rendered for me whether paid by said insurance or in the event I am not eligible for insurance. I hereby authorize and assign to release all information necessary to secure payment.

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/Guardian signature:

Date:

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED

HEALTH INFORMATION

With my consent, Leon W. Lewis MD, PC may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Leon W. Lewis MD, PC’s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. So, Leon W. Lewis MD, PC reserves the right to revise its Notice of Privacy at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Office of Leon W. Lewis MD, PC at 420 Lowell Drive, Suite 401, Huntsville, AL 35758.

With my consent, Leon W. Lewis MD, PC 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 results among others.

With my consent, Leon W. Lewis MD, PC 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 if they are marked Personal and Confidential.

By signing this form, I am consenting to Leon W. Lewis MD, PC use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Leon W. Lewis MD, PC may decline to provide treatment to me.

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.

Print Patient’s Name:

Signature of Patient or Legal Guardian:

Date:

For Practice Use Only: The practice made a good faith effort to obtain the patient’s written acknowledgement of receipt of the privacy practices notice. The patient’s written acknowledgement was not obtained for the following reason:

Refused Emergency Other

PATIENT AUTHORIZATION FOR PRACTICE TO RELEASE PROTECTED HEALTH INFORMATION TO THIRD PARTIES

By signing this authorization, I authorize Leon W. Lewis MD, PC to use and/or disclose certain protected health information (PHI) about me to or for the party or parties listed below. This authorization permits Leon W. Lewis MD, PC to use or disclose to any laboratory, hospital, or other physicians or insurance company, the following individually identifiable health information (such as date(s) of service, level of detail to be released, origin of information, etc.): as it relates to my care at Leon W. Lewis MD, PC.

This authorization will expire on:

When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that Leon W. Lewis MD, PC has acted in reliance upon this authorization. My written revocation must be submitted to Leon W. Lewis MD, PC Privacy officer at 420 Lowell Drive, Suite 401, Huntsville, AL 35801.

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’s Print Name:

Patient’s Signature:

Date:

I authorize Leon W. Lewis MD, P.C. to disclose or provide my protected health information to the following individuals who are authorized to act as my personal representative for the purpose of receiving all protected health information about myself. As my designated personal representative, they may exercise my right to inspect, copy, and correct my protected health information.

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OFFICE POLICIES

OFFICE HOURS AND GUEST
Our office is open Monday-Thursday 8:30am to 5:00pm, Friday 8:30am to 12:00pm and may be reached on 256-489-8845. We are closed for most major holidays. Currently, we do not offer “walk-in” appointments. We offer an after-hours answering service that can contact the on-call provider for urgent issues. We welcome you to use this service anytime you have serious concerns or questions. In the case of extreme weather, we may close the office, so it does not compromise the safety of our staff & patients. In such instances, we utilize patient approved communication methods to send automated notifications by text/e-mail/portal messages/voice calls.

No children or guests are allowed in exam rooms except: (1) Newborns (8 weeks and younger) in carriers; and (2) One adult guest for the first new OB visit & OB ultrasounds only (Guest is allowed in our lobby only if seating is available.)

PATIENT REGISTRATION
At the time of registration, and periodically thereafter, you will be asked to complete a registration package. This will help our personnel keep insurance information and demographics accurate. You will be asked to present a photo ID and current insurance card(s) at the time of registration, and periodically thereafter. We will make a copy of your insurance card and ID. If you get a new insurance card or photo ID, please bring it in so we can make sure it’s current in your records, even if it is the same policy, because the billing information may have changed. You may not have to show your ID or insurance card after the first time you show it, but you should always have it just in case.

MESSAGES
We strive to return patient calls as soon as possible. Non-urgent calls and messages will be returned within 24 hours. Please call our office directly for any urgent issues and go to the nearest emergency room or call 911 in the event of any life-threatening emergency.

LATE ARRIVAL, CANCELLATION, AND NO SHOW
If you arrive more than 15 minutes late for your appointment, you may be asked to reschedule for you to have ample time to get your health concerns addressed.

We ask that you kindly give at least 24 hours’ notice when canceling or rescheduling an appointment.

We will charge $50.00 for missed appointments, or appointments canceled or rescheduled less than 24 hours after your appointment. By failing to cancel or reschedule your appointment three or more times we reserve the right to dismiss you from our practice.

Every patient I care for is entitled to and will receive the best care that we can provide. Considering medical seminars, meetings, and periodic vacations, it is humanly impossible for any physician to be available 24 hours a day, 365 days a year. I will do my best to be there for your delivery but may not be available when you deliver. This does not mean that you will not receive the medical attention that you require.

If I am not available, another equally qualified doctor will provide medical care for you. These arrangements help assure us that you will be cared for by a physician who is Able to function at peak efficiency. The on-call physician will provide care for labor and Delivery, gynecological problems, and emergency room visits.

In case of emergency, please call my office phone number and the exchange will put you in contact with the on-call physician. If you are having an emergency, and your call is not Returned immediately, proceed directly to the hospital, or call 911. In case of non-emergency Calls, the on-call physician will call you back as soon as possible.

When calling the physician for a problem, please have your pharmacy’s phone number Ready in case a medication needs to be prescribed. If you have any questions, please do not hesitate to ask at the time of your visit.

FINANCIAL POLICY

Thank you for choosing Leon W. Lewis MD, PC. We are committed to the success of your treatment. We hope you understand the payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to and sign, prior to any treatment. This financial policy applies to all services rendered by the doctor or nurse practitioners.

It is our policy that the patient, rather than the insurance company, is for complete payment of our charges. All patients with insurance coverage are required to pay for non-covered services, any deductible amount not previously met, and any copay amount due at the time of services are rendered. For patients with dual insurance coverage, we will bill both the primary and secondary insurance if you have provided us with the necessary information.

Patients insured with plans which we are NOT contracted with or DO NOT have insurance will be required to pay as an “Out of Pocket Patient” for the initial consultation in full. For any follow up visits, patients will need to pay accordingly. There may be 80% or more down payment prior to any surgery needed.

For prescriptions, if you need a refill, please have your pharmacy fax a request to (256) 265-4340. (Please allow 48 to 72 hrs.) No pain medication will be given to post-operative patients after 90 days of surgery. Our physician DOES NOT prescribe pain medications to chronic pain patients. Patients with chronic pain syndrome are referred to pain management specialists for long term management.

FEES AND PAYMENTS Physicians share the concern of their patients regarding the increasing cost of medical care. Our fees are within the customary range for this area and reflect the high level of care you will receive. We have standardized charges for various procedures, but these can vary depending on unforeseen circumstances that might arise. If you have any questions about fees, we encourage you to discuss them with our business office.
The fees for obstetrical care include all routine obstetrical care from your first visit through your prenatal care, your delivery and your post-partum visit six weeks following delivery. If a cesarean birth is necessary, there will be additional charges.

ALL MEDICAL BILLS ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED FOR CASH PATIENTS
We accept payments by cash, personal checks, Mastercard, Discover, American Express and Visa. This will help control the expensive process of billing and collections. If your medical services are greater than anticipated, we will be happy to arrange a payment plan with you. If you are having financial difficulty, please contact our business office.

INSURANCE
Please remember that your insurance coverage is a contract between you and your insurance carrier. Please contact your insurance company to verify that your doctor is a provider with your insurance. If you wish to file an insurance claim, we will furnish you with an itemized statement of your services and diagnosis, if one is established, and you can forward this statement on to your insurance company.

Payment for services rendered is expected at the time of each visit, regardless of your insurance coverage. In some cases, your insurance company will only cover a portion of our fees. Since our relationship is with you and not your insurance company, our bill is your responsibility. We would appreciate it if you would give it prompt attention. We will be glad to help you if you have a problem with your claim.

PPO INSURANCE

If you are a member of a Preferred Provider Organization (PPO) and our office has signed a contract to provide services for your PPO, we will handle all the billing of your insurance. You MUST provide us with a copy of your insurance card at the time of service. You are REQUIRED to pay any co-payments at that time. If you require lab work, it will be sent to an outside lab. Certain PPO’s have contracts with specific labs. You will be given a referral slip and you may go to that lab for your test.

If you do not ask for a referral, we will Send your specimen to our usual lab, and we WILL NOT be responsible for any outside lab fees that you may be charged. We realize this can be confusing and we will work with you in any way we can to maximize your insurance benefits.

HMO INSURANCE

If you are a member of a Health Maintenance Organization (HMO) and our physicians have signed a contract to provide services for your HMO, we will handle all the billing of your insurance services. Our doctor, in this practice, cannot be listed as your primary care physician. He is a SPECIALISTS. You are required to pay any co-payments at the time of service.

There will be a fee of $100 for any surgery cancellation. These fees will offset the surgical preparations which are separate from the surgical facilities. If you are insured with a plan, which we ARE contracted with (including Medicare and Medicaid), you will need to pay for any noncovered services, any outstanding deductible, and your copay amount at time of each visit.

There is a fee of $25.00 or more for all disability, FMLA and any other forms/paperwork that you need to have filled out by the physicians. We may ask that you make an appointment to complete these forms. There is a fee for any reports or medical records requested by attorneys, insurance companies, disability companies, etc. This change will be determined by the information requested.

Our accepted methods of payments are VISA, Discover, American Express, and MasterCard, cash, and checks. There will be a $50 fee for any bounced checks, thereafter, patients are required to pay with ‘cash’. If requested a short payment schedule may be arranged for those patients who have special financial conditions.

It is the patient’s responsibility to verify their benefits for their specific plan and to make sure all proper authorizations have been obtained. Some insurance plans will reduce benefits if the insured is treating the doctors outside of the designated network or if the proper authorizations have not been obtained.
Again, thank you for trusting us with your obstetrical care and gynecological. If you have any questions regarding financial responsibility or payment options, please contact our office.

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.

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