PLEASE READ THE FOLLOWING CONSENTS AND SIGN AND SUBMIT AT THE BOTTOM OF THIS FORM IF YOU AGREE
**PLEASE CAREFULLY READ THE FOLLOWING INFORMATION BEFORE SIGNING**
PATIENT FINANCIAL RESPONSIBILITY
Presken Family Care, P.C. (“PFC”) is committed to providing you with the best possible medical care. In order to do so, we believe that it is important that you clearly understand the information contained in this Patient Financial Policy. We ask that you read, sign, and return to us this document prior to your first visit of 2022. If you have any questions about your financial responsibility explained in this document, please don’t hesitate to contact our billing service at 303-791-1987.
APPOINTMENT CANCELLATION AND “NO-SHOW” POLICY: PFC will charge you a $50 fee for failing to attend a scheduled appointment (video visit or in-person) and for cancellations occurring less than 24-hours before your scheduled appointment time. Although we understand that personal circumstances may make it necessary for you to cancel or reschedule your appointments from time to time, we request that you notify us of your need to cancel or reschedule as soon as possible. Short-notice cancellations and missed appointments prevent us from offering the appointment to other patients wishing to be seen by PFC. Also, please note that a frequent pattern of appointment cancellations and/or missed appointments makes it difficult for PFC to provide you with an appropriate continuity of care, and may result in the need to discharge you from our practice.
PATIENTS WITH HEALTH INSURANCE COVERAGE: As a courtesy, we will bill your health insurance provider directly for medical services rendered to you by PFC. However, your health insurance plan is a contract between you and your health insurance provider. Coverage varies widely between health insurance providers, and even between different health insurance plans offered by the same health insurance provider. Ultimately, you are responsible to know your insurance benefits. Below are some PFC policies that you should be aware of regarding your health insurance benefits.
Insurance Verification. You are responsible for providing PFC with complete and accurate information regarding your health insurance plan. We will verify your health insurance coverage at the time of your visit and again shortly before each scheduled appointment time. To assist in verifying your health insurance coverage, you are responsible for providing PFC with your current health insurance card (or other proof of insurance) prior to every visit. If your health insurance coverage changes after you schedule your appointment with PFC, please notify PFC as soon as possible before your scheduled appointment. If PFC is unable to verify your active health insurance coverage prior to your treatment time, it may become necessary to reschedule your appointment or to treat you as a “self-pay” patient.
Copayments. You are responsible for paying PFC any copayment required by your health insurance plan. Copayments are a part of your contract with your health insurance provider. We are aware that some health insurance providers sometimes do not assess a copayment or assess a different copayment when they process the claim.
Deductibles. Some commercial and managed care health insurance plans also include an annual deductible amount that must be paid by the patient before the health insurance plan pays any benefits. If you have not met your deductible, your health insurance provider will process the claim towards your deductible, but will not make any payment to PFC (or will make payment for only the amount in excess of the deductible). If this occurs, you will be responsible for payment of any remaining balance not paid for by the health insurance plan, in accordance with the contracted rate under such health insurance plan.
Non-Covered Services. Your health insurance plan spells out your specific coverage and varies greatly from plan to plan. Please be aware that some of the services that we provide may be determined by your health insurance plan to be non-covered. You will be financially responsible for the costs of any such non-covered services or services that your insurance plan denies as being “not medically necessary”.
Medicare Patients. For Medicare patients, PFC submits claims to the Medicare program in accordance with Medicare billing rules. In the event that our information indicates that a specific service or services may not be covered by the Medicare program, we will ask you to sign an Advanced Beneficiary Notice form (“ABN”) outlining the services that we have determined may not be covered by Medicare. Pursuant to the ABN, you must agree to be financially responsible for any billed amounts not covered by the Medicare program prior to PFC agreeing to render any such services.
Out-of-Network Services. Although we are a participating provider in many health insurance plans, we do not participate in all health insurance plans. If your health insurance plan is a plan with which we do not participate, we may still provide services to you. However, please note that you may have an out-of-network deductible, higher copayments, and/or coinsurance, which may be higher than if you were to receive services from an “in network” provider. Moreover, it is important to note that, as an out-of-network provider, PFC may not be able to determine the exact health insurance benefits applicable to out-of-network services until the payor receives and processes the claim. If we provide services to you as an out-of-network provider, you will be responsible for the entire bill, or the balance of the bill, if the claim or any portion of the claim is denied by your health insurance provider.
Referrals. All referrals to specialists will require a visit with Dr. Presken. Referrals can take up to three business days for PFC to process. If you require a referral to a specialist provider, certain approvals may be needed from your health insurance provider. Once submitted to your health insurance provider, these approvals may take as long as 72 hours for processing. Accordingly, please allow as much time as possible prior to scheduling your appointment with the specialist. Please note, PFC only recommends a specialist - it is your responsibility to ensure that the services of such specialist are covered by your health insurance plan.
PATIENTS WITHOUT HEALTH INSURANCE COVERAGE (“SELF-PAY”): If you do not have health insurance coverage we can still provide services to you but you will need to pay us the current fees for new patient and existing patient visits.
PAYMENT AND COLLECTIONS: Our practice accepts cash, personal checks, debit cards and credit cards for payment. If the balance on your account is 90 days or more past due your account balance will be subject to placement for outside collection. In the event your account is placed in collection status, any additional fees incurred will be added to the outstanding balance, including, but not limited to, late fees, collections agency fees, court costs, interest, and fines. These additional fees will be your personal responsibility. A patient with unpaid delinquent accounts or accounts written-off to bad debt may not receive additional scheduled services and may be discharged from the practice.
PATIENT ASSIGNMENT, AUTHORIZATION, & ACKNOWLEDGMENT: By signing this document, I agree to each of the following statements:
• I acknowledge my understanding of, and agreement to, the information presented to me in this document;
• I assign and transfer to Presken Family Care, P.C. all of my rights, title, and interest in any health insurance benefits or other medical benefits, including Medicare (as applicable), that I am eligible to receive for services rendered by Presken Family Care, P.C., which shall remain valid until I provide written notice to PFC revoking such assignment;
• I authorize the practice to release any information, in compliance with HIPAA requirements, to my health insurance provider when requested or to facilitate the payment of any claim, which shall remain valid until I provide written notice to PFC revoking such authorization; and
• I acknowledge and agree that I am financially responsible for payment of the services provided to me by PFC and, accordingly, I am responsible for payment of any portion of my bill that is not paid by my health insurance plan.
NOTICE OF PRIVACY PRACTICES
Consent for Purposes of Treatment, Payment and Health Care Operations: I understand that, as a condition to my receiving treatment from Presken Family Care, they may use or disclose my personally identified health information for treatment to obtain payment for the treatment provided and as otherwise necessary for the operations of Presken Family Care. While I am here, I permit the employees, the doctor and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand the attending physician will explain to me the nature of my condition, her recommended treatment and any associated risk involved. I also understand that she will explain to me other ways this condition could be treated. I further understand that this care may include diagnostic testing, examinations, and medical and/or surgical treatment, and that no guarantees have been made to me about the outcome of this care. “Personally identifiable health information” refers to health and demographic information collected about me by my physician (or other health care provider, public health authority, health plan, employer, life insurer, school or university, or health care clearinghouse) that relates to my past, present or future physical or mental health or condition or payment for provision of health care. The information identifies you, the patient, or there is a reasonable basis to believe that the information may identify me.
I understand that privacy practices may change over time and that I have a right to obtain any revised Privacy Notice by contacting Presken Family Care to make such a request. I may receive a revised Notice of Privacy Practices by calling the office and requesting a revised copy by mail or by asking for one at my next visit. I also understand that I have the right to request Presken Family Care to restrict how my health information is used or disclosed. Presken Family Care does not have to agree to my request for the restriction, but if Presken Family Care does agree, Presken Family Care is bound to abide by the restriction as agreed. Finally, I understand that I have the right to revoke/withdraw this consent, in writing, at any time. My revocation/withdrawal will be effective except to the extent that Presken Family Care has taken action in reliance on my consent for use or disclosure of my health information. Provision of future treatment may be withdrawn if I withdraw my consent.
Medicare Lifetime Consent & Medicaid: I certify that the information given by me in applying under Title XVII of the Social Security Act is correct, and I authorize any holder of medical or other information about me to release it to the Social Security Administration or its intermediaries or carriers as needed for this or a related Medicare claim. I assign the benefits payable for the physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.
Personal Representative Designation: Presken Family Care (PFC) may discuss or release personal health information to the personal representative(s) regarding eligibility, billing, payment status, benefits, claims, medical information used to make payment decisions, providers, appeals and complaints about my health insurance coverage through Presken Family Care. PFC is authorized to release personal health information to the person(s) named as my personal representative for the purpose of assisting with, or facilitating, the coordination/payment of my health plan benefits. I also understand that if my personal representative is not a health care provider or other person subject to federal privacy laws and that my personal health information may no longer be protected by those privacy laws and may be subjected to re-disclosure. PFC is not responsible should my personal representative further disclose my protected personal health information. I further understand that I have the right to limit the information that you release under this authorization. Limitations for disclosure are identified below, and a copy will be put into my file; unless indicated, no limitations will apply. This authorization will automatically expire one (1) year following the termination of my health plan enrollment or anytime sooner upon written notification by me.
Participation in the CORHIO HIE: Presken Family Care endorses, supports, and participates in electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience. HIE provides us with a way to securely and efficiently share patients’ clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who are treating you to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the CORHIO HIE, or cancel an opt-out choice, at any time.
I agree to participate in telemedicine evaluations with Presken Family Care. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care.
Note: The likelihood of this transmission being intercepted by persons other than those at the doctor’s office is extremely small.
I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation.
Note: If you would like to withdraw from telemedicine evaluations with Presken Family Care, please contact our office at 720-556-2001.
I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person.
I understand that my telemedicine evaluation may be billed to my health insurance for reimbursement for care provided for Presken Family Care.
CONSENT TO OBTAIN PATIENT MEDICATION HISTORY
Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance. Also over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.
I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.