Currently contracted with PPO, Medicare, and Tricare plans:
Allergy skin testing and Sublingual Immunotherapy (Suite 105)
Radiology: Ultrasound by appointment only (Suite 105), X-Ray – walk in OK (Suite 116)
Laboratory – West Pacific, not affiliated with Grace Family Health (Suite 116)
As a courtesy please call us to cancel appointments at least 24 hours in advance. All appointments not cancelled within 24 hours will result in a $50 charge. Patients with a history of 3 appointments with less than 24 hour notice, 3 no shows or a combination of both will be seen on a walk-in basis only.
3. Copays, Deductibles, Pre-Payments, EOBs and Balances Due
Payment is required for each office visit including follow-up, re-checks, and telephone consultation appointments, if offered and scheduled, with physician, physician’s assistant or nurse practitioner.
Co-payments must be paid at the time of check-in
If we determine you have an unmet deductible you must pay an estimated deductible deposit of $95. We will bill your insurance and if there is a balance due you will receive a statement. If there is an overpayment on your account, we will refund you via check or credit card.
Alternatively, you may sign a card on file agreement where your credit card info is securely stored within our EHR. Once we receive an EOB from your insurance company we will charge the charge on file any amount due.
If you have an unpaid balance from prior visits, we require that you pay this balance in full prior to any further services are rendered.
Nurse Visits: • Vaccine injections • Urine dip for poss UTI • Blood pressure recheck • Forms/Insurance papers
B. Is Copay required?
Physical/Preventive : • No copay if – only preventive • Yes applicable if refills are needed, discover or treat new or chronic problems, symptoms, or findings
Non-Preventive Visits: • Yes – depending on insurance • *If urgent care visit – collect urgent care level copay (sometimes higher) • If primary care appointment – collect regular office co pay
Nurse Visits: No, unless the test is positive, then the visit is converted to a same day appt to see a provider for treatment
C. Have you met your deductible?
Physical/Preventive : Not Applicable – usually preventive visits do not apply to deductible.
Non-Preventive Visits: • If Yes: only collect co pay • If No: at check in front desk will collect a $95 deposit which will be applied to your deductible. If insurance pays, we will refund you.
Nurse Visits: • If Yes: no copay needed • If No: we will collect the cash rate for tests or injections and will issue refund if your insurance pays.
5. Insurance Benefit Assignment:
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, Medicare, private insurance and other health plans to Grace Family Health, Inc. dba Murrieta Express Care. I hereby authorize my insurance benefits to be paid directly to Grace Family Health, Inc.
I hereby instruct and direct my insurance company to pay by check or electronic funds transfer, made payable to Grace Family Health, Inc. and mailed to: 24910 Las Brisas Rd, Suite 105, Murrieta CA 92562; or address on the statements or envelope provided by our billing service company.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I hereby authorize said assignee to release all information necessary transmittal, electronically via the internet, or hard copy.
6. Accurate and Current Information:
All patients must provide accurate and complete personal and insurance information including a current picture ID or driver’s license, so we can properly identify you as the insured individual. In the event that we are unable to collect from insurance in a timely manner due to your error or lack of cooperation, you will be responsible for the entire billed charges.
7. Limitations of Health Plan Benefits/Coverage:
I understand that I am personally liable to pay for billed services which my insurance company or managed care company will not cover if they deny the claim and say that an office visit, procedure or pathology etc., is “not medically necessary”, “preexisting”, “third party liabilities such as car accidents or work-related injuries” or for any other reason they give for non-payment.
I also understand that what my carrier considers “not medically necessary” may, on the contrary, be considered medically necessary by physicians and providers in this office. If laboratory, radiological, or other tests, or medications are not covered, or denied by the utilization committee of the health plan administrators or their policies, patients have the option to choose to pay for these services outside of covered benefits or pursue an appeal as an insured/enrollee directly with the health plan/insurance companies. This office will cooperate with supplying clinical notes and codes necessary for the process of the appeal, but it is not the medical office’s duty to pursue and engage in dispute with written policies or limitations of coverage that patients have already agreed to at the time of selecting the policies that fit the family budget or that are offered by the patient’s employer.
Therefore, I agree to hold all officers, owners, and associates of Grace Family Health, Inc. dba Murrieta Express Care harmless for any medical decisions made by my insurance company or managed care organizations, which may in any way compromise my best care and results in medical damage, loss or death.
8. Insurance Network Limitations Disclosure:
Grace Family Health, Inc. dba Murrieta Express Care patriciates in plans administered by Anthem/Blue Cross, Blue Shield, Aetna, Cigna, United Health Care, Health Net, Tricare, Coventry and many other PPO plans. We are also contracted to serve Medicare Advantage HMO patients administered by Temecula Valley Physicians Medical Group. It is the sole responsibility of the patient or patient’s insurance policy holder, guarantor, or guardian to verify they are in network with our office.
These insurance affiliations and contracts are subject to change without notice, due to expiration of contracts, plan mergers, government healthcare reform regulations, etc. Within each company, for example, Aetna, many different types of plans and benefits are offered, and we may or may not be a participant of ALL the plans for that insurance company. Moreover, insurance companies do not always update their directories in a timely manner.
For these reasons, despite our state-of-the-art real time health information technology, it is impossible to, and NOT our responsibility to, verify and ensure that your insurance plan is in fact in network with us. Therefore, if after submitting for reimbursement from your insurance, your health plan determines that our practice is NOT in network with your selected insurance plan, you will be responsible to pay for the entire billed amount, or any balance remaining after your insurance pays a portion of the fees if your plan paid the bill partially, as some plans include a limited out-of-network coverage.
9. Medication Refills:
Policies are set with the goal to ensure optimal patient safety and monitoring.
We cannot and will not provide refills for urgent care only patients. Please see your PCP for all refills.
Some medications such as antibiotics, antifungal, cough or nausea always require exam – no refills.
Pain management is out of the scope of this practice – all chronic narcotics will be managed by specialist.
Ask your pharmacy to send request directly to us. Give at least 1-week lead time before running out.
Most chronic conditions need follow up exam and labs every 3-6 months before safely refilling meds.
10. Lab/Radiology Results:
It is your responsibility to complete labs and other tests recommended and/or ordered in a timely manner.
All results (except confidential testing) are posted on secure patient portal unless you declined access.
Please review your results on the portal, if no portal access, bring a picture ID to get a paper copy at the office.
If any abnormal results or any unresolved symptoms, you need to schedule an appointment for further evaluation.
11. Patient portal use:
Purpose of the portal is to facilitate communication and collaboration and not for telemedicine visits.
Use it to: make appointments, pay your balance, check in online from home, quick clarifications
Do not use portal to discuss results, ask about new symptoms, ask for referrals, or to request a new prescription.
12. Prior Authorizations
– of non-covered medications, supplies or referrals.
Insurance will listen to patients more than doctors. Call them to appeal if you receive a denial.
It makes no sense, but these days many insurance companies don’t cover even some of the inexpensive generic or over-the-counter medications. However, you can usually find affordable discount generic drugs using online coupons such as GoodRX.com. No prior auth is needed.
Generic alternatives often are required before brand name approval is granted by the insurance company. If clinical outcome is not optimal due to this limitation - your insurance company is responsible, not us.
13. Letters/Disability Forms/Miscellaneous Forms:
No fee for 1-7-day work/school notes.
Completion of school, work, administrative, and disability forms are not routinely covered by insurance. Because these forms take a significant amount of time, it is customary and necessary to charge a fee for completion of such forms. Examples include, but are not limited to: jury duty excuse, housing accommodations, transportation, Family Medical Leave Act (FMLA), certain disability forms, accident reports, and certain DMV forms. The current fee for these forms is $25.
The administrative costs for these items are NOT covered by insurance and a nominal fee is required to cover our cost. ($25 for all forms)
14.Responsibility for Disability paper
The specialist who is in charge or your disabling condition is also naturally responsible to handle your disability paperwork.
We do disability forms for those not seeing specialists for their disability, or for short term (under 2 weeks) before you see your specialist. Once you have been referred to a specialist, they will be responsibility to complete those forms.
15. Medical Records
No charge for sending other treating physicians a copy of records.
Medical record requests for disability, life insurance, lawyers, etc. are charged $15 per request.
Patients requesting a paper copy of their records are charged $15.
16. Medication History Electronic Download Authorization
Our electronic health system obtains your medication history from a national pharmacy network. This information is not downloaded automatically and requires your consent.
Your signature below is your consent for us to obtain this information in order to better evaluate your medical needs and facilitate more accurate continuity of care, as well as improve collaboration of care amongst the various member of your healthcare team.
17. Authorization and Consent for Medical Treatment
I, the undersigned patient, guardian or authorized legal representative of the patient, hereby authorize Grace Family Health, Inc. dba Murrieta Express Care and any associates as designated by the medical director, to perform evaluation and treatment of my medical condition. I further request and authorize all clinicians (physicians, physician assistants, nurse practitioners, and/or any other clinical staff members employed by Grace Family Health, Inc. dba Murrieta Express Care, to perform additional procedures, as they may deem immediately necessary on an emergent basis.
I understand that elective minor surgical procedures will be consented via verbal discussion prior to being performed.
I consent to elective minor surgical procedures, joint or muscle injections, and the administration of medications, vaccines, and injections (upon verbal consent and cooperation) deemed necessary in the judgement of the medical director, and any associates and assistants as designated by the medical director of Grace Family Health, Inc. dba Murrieta Express Care.
I recognize that the practice of medicine is not an exact science, Grace Family Health, Inc. dba Murrieta Express Care and its associates do not guarantee the results of any advice and/or treatment given.
18. Late payment fee and collection agency fees:
Within 30 days of receiving a billing statement, any additional payment not made at the time of service is expected in full. b. All accounts will be assessed a $10 late fee per month, on all unpaid balances greater than 30 days following the date of the first billing statement. c. Any outstanding unpaid balances will be sent to a collection agency 90 days after the first statement has been sent to you. The collection agency fee and/or associated administrative and legal fees, including attorney’s fees, shall be your responsibility.
All accounts will be assessed a $10 late fee per month, on all unpaid balances greater than 30 days following the date of the first billing statement.
Any outstanding unpaid balances will be sent to a collection agency 90 days after the first statement has been sent to you. The collection agency fee and/or associated administrative and legal fees, including attorney’s fees, shall be your responsibility.
19. Un-Insured Patients and Third-Party Liabilities (not covered by insurance)
If I do not have any insurance coverage, I understand that I must pay in full for all services rendered on the date of service at the time of checking in.
If the visit is for a work injury or stress, car accident, or public place injury, there are not covered by health insurance, and financially I will be as an uninsured patient for this visit. All services must be paid up front, in full, at the time of service and a receipt will be made available for me to submit to my auto insurance, employer, or other third-party for reimbursement.
There are no billing statements, or payment plans for these un-insured visits.
Please help us do an even better job serving you, by providing your ideas, comments and feedback. Feel free to confidentially communicate regarding our practice. Go to our website: www.GraceFamilyHealth.com or www.MurrietaExpressCare.com and fill out the feedback form. These forms are sent directly to the management team.
Call Extension 9 and leave a voicemail. You will hear back from management within 5 business days.
I, the undersigned patient, or parent/guardian to patient, hereby acknowledge and accept these policies.
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.