WELCOME PACKET

WELCOME TO OUR PRACTICE!

Please take a few minutes to answer the following questions so we can better assist you with your health care needs. Thank you!

PATIENT INFORMATION

Last Name

First Name

Middle Initial

Birthdate:

Sex:

M F

Home Phone:

Cell Phone:

Address:

City:

State:

Zip:

In Case of Emergency, who should we contact?

Name:

Relationship to Patient:

Phone #:

Preferred Pharmacy Name

Address

LEGAL GUARDIAN INFORMATION

Name of Legal Guardian 1:

Occupation:

Name of Legal Guardian 2:

Occupation:

Email Address for Online Portal Access:

PRIMARY INSURANCE

Person Responsible for payment of account:

Relationship to Patient:

Birthdate:

Social Security #:

Phone #:

SECONDARY INSURANCE

Person Responsible for payment of account:

Relationship to Patient:

Birthdate:

Social Security #:

Phone #:

ASSIGNMENT AND RELEASE

I hereby authorize payment directly to Dr. Nava Segall for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize Dr. Nava Segall to release the information required to secure the payment of benefits. I authorize this signature on all insurance submissions.

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.

Signature of Responsible Party:

Date:

BILLING FREQUENTLY ASKED QUESTIONS

1: I am now receiving bills for services that were previously covered by my insurance. Why has the Pediatrics Office changed its billing practice?

The Pediatrics Office has not changed its billing practices in any substantial way for many years. What has changed is your insurance coverage. When you enroll in a health insurance plan, you are signing a contract that dictates whether specific health care charges are the responsibility of you or the insurer. We at Nava Segall, M.D. Pediatrics have no control over the specifics of this contract.

2: My child was seen for a well-child checkup. Why was I also billed for a sick visit?

Our contracts with health insurers dictate a certain level of payment for well-child checkups. Well-child checkups include an assessment of growth and development, a screen for medical and psychological problems, anticipatory guidance to aid parents in the next steps of their child’s development, a review of the child’s vaccination status and updates as needed, and the generation of a “health form” that clears children for participation in school, sports, and camp activities. In the course of performing a well-child checkup, your physician will be happy to address any specific concerns or questions that you have about your child’s well-being. Many of these are simple questions that can be addressed quickly and clearly fall within the scope of a regular checkup.

In some instances, a more significant health problem will be identified at the well-child visit, or a chronic medical issue will be discussed. If so, the time and effort your physician spends addressing these health problems go beyond the scope of what is covered as part of a well-child visit. Some examples of such scenarios include:

The recognition of a new medical problem.
A discussion of a chronic medical issue.

When these scenarios arise, your physician will generate a billing code for well-child visits treated at the same visit. This is standard billing practice among all primary care providers (pediatricians, internists, and family practitioners). Modifier codes are accepted as standard practice by government agencies and by private health insurers.

In the past, many health insurance plans covered these “modifier” billing codes in full. As insurance coverage has evolved, however, an increasing number of patients are now being asked to pay either the full cost of these modifiers billing codes or a co-pay for the modifier portion of the total visit.

Again, our billing practices have not changed, nor has our contract with the insurers in this matter. What has changed for many of you is the contract you have signed with your insurer.

3: I understood that I had no copay for well visits. Why was I charged a copay for my child’s recent visit?

As per question #2 above, this scenario usually occurs when the patient was billed not only for a well visit but also for a simultaneous sick visit using a “modifier” code. Your insurance coverage may dictate that you are responsible for the co-pay for the sick visit portion of the bill. It is not our decision to charge you a co-pay. Your copay results from your contract with the insurer.

4: Why am I being charged a $25 no show fee?

In order to provide the same comprehensive, professional and compassionate care we have made changes in our appointment policy starting January 1, 2015. We realize that unexpected events can happen, but in order to see patients in a timely manner and be able to accommodate those needing urgent appointments we have put a no show fee in place. We are requiring 24 hours notice for any changes or cancellations to appointments. Any changes or cancellations within the 24 hour period will incur a $25 no show fee and will be due prior to entering the next appointment.

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.

Name:

Signature:

Date:

NAVA SEGALL ACKNOWLEDGEMENT

I hereby acknowledge receipt of the Notice of Privacy Practices.

Patient’s Name:

Date of Birth:

S.S.N.:

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 Signature:

Date:

If this acknowledgement is by someone other than the patient (a personal representative) please complete the following:

A personal representative is a person legally authorized to act on behalf of an individual for health care decisions, including, in most cases, a parent of a court appointed guardian, executor or administrator.

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.

Personal Representative’s Name:

Personal Representative’s Signature:

Relationship to Patient:

If unable to obtain written acknowledgment of receipt of the Notice of Privacy Practices, document good faith efforts to obtain acknowledgment and the reason why the acknowledgment was obtained below.

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.

Signature of Practice’s Workforce Member:

Print Name:

Date:

Well Care Verification

By providing us with the following information you will be assisting us in the best immunization program for your financial needs

Please provide us with the following

Insurance Company Name

Child/Children Name

Does your insurance cover well checks?

Yes No

Does your insurance cover immunizations?

Yes No

Do you have a deductible?

Yes No

deductible amount

Does your well care have a dollar amount maximum per year on well care?

Yes No

If so, how much?

It is your responsibility to inform us if any of the above information changes. We will have you initial at every care visit to verify the information prior to giving immunizations in the event the information given is incorrect and there is a balance at your well care visit we may have you reschedule your appointment until the balance is resolved.

Any well care given by VFC will be payable at each time of service.

Please keep in mind that the Chicago Department of Public Health is an option for immunizations if you have no insurance coverage for vaccines

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.

Please sign and date

Date:

Patient Name:

Address:

Phone Number:

Date of Birth:

AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION

I hereby authorize that the protected health information regarding the above-named person be forwarded:

FROM:

Person/Institution:

Phone:

Fax:

Address:

City:

State:

Zip Code:

TO:

Person/Institution: Nava Segall

Phone: 773-883-2350

Fax: 773-883-2351

Address 4116 N. Lincoln

City: Chicago

State: IL

Zip Code: 60618

Purpose or need of information:

What is being authorized for release?

Please check and initial the specific protected health information you are authorizing be used and/or disclosed (if this authorization is for psychotherapy notes, no other type of protected health information may be listed on this authorization).

General Medical

Initial

Genetic Testing

Initial

Mental Health

Initial

HIV/AIDS

Initial

Alcohol/Substance Abuse

Initial

Physician Name/Dept. of Service

Initial

Other (Please specify):

I must check one of more of the following types of health information that I do not want released to the above named recipient. I understand that if I do not check any of the three (3) following boxes, the health information released to the named Recipient may include any of the following:

Diagnosis, Evaluation and/or treatment for alcohol and/or drug abuse

Records of HTLV-III or HIV testing (AIDS test) result, diagnosis and/or treatment

Psychiatric, psychological records of evaluation and/or treatment for mental, physical and/or emotional illness including narrative summary, test, social work assessment, medication, psychiatric examination, progress notes, consultations, treatment plans. And/or evaluation.

I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to the medical record contact at this site of care except to the extent that action has already been taken to release this information. This authorization shall remain valid unless revoked by will expire in 1 year after signing. I have a right to inspect a copy of the health information to be released and if I do not sign this Authorization, the institution named above will not release my health information. The above named person/institution will not refuse to treat me based on whether I agree to allow my health information to be used and disclosed to others.

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.

Signature of Patient

Date of Birth:

Signature of Parent/Legal Guardian/personal Representative

(Required if Patient is not legally authorized to sign Authorization)

Relationship to Patient

REDISCLOSURE: Notice is hereby given to the patient or legal representative signing this Authorization that Nava Segall M.D.S.C. cannot guarantee that the recipient receiving the requested health information will not redisclose any or all of it to others. Notice is hereby given to the Recipient that prohibits the redisclosure of any health information regarding drug and/or alcohol abuse, HIV and mental health treatment.

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