Welcome to our office!!
Enclosed you will find our new patient paperwork. Please complete and sign all of these forms prior to your appointment. If you have any questions regarding any of the information requested, please call our office prior to your visit date. We do require that all the enclosed forms, including the arbitration agreement be completed and signed. We realize this is a lot of paperwork, therefore we request that you mail the forms back to our office or that you arrive 30 minutes early on the day of your appointment. If previous medical records are necessary for your appointment, please forward the records in advance to facilitate your visit.
Work Hours:
The office is open from Monday to Friday, 9 AM to 5 PM, except on Wednesdays from 9 AM to12 Noon; the office is closed for daily lunch from 12-2 PM, and on weekends and holidays.
Scheduling routine well check visits and/or routine physical exam visits:
You understand that Dr. Quintanilla will explain which regular health screenings are appropriate for the patient's age, gender and/or personal/family history; you understand that there are recommended health screening visits and tests that can help detect life-threatening diseases and conditions, if you visit the doctor only for immediate problems and forget to arrange for regular health screening visits, you put your child at risk of letting serious health problems going undetected, therefore you understand that you will schedule regular visits to complete physical exams and to allow regular health screenings to be performed.
Follow-up Appointments and Missed Appointments:
You understand that Dr. Quintanilla needs to know about the progress of a condition after leaving the office and returning to the doctor on time gives him the chance to check on the condition and the response to treatment. If you cancel or miss your appointment and do not re-schedule you run the risk of the physician not being able to detect and treat a serious health condition. Therefore, you will make every effort to re-schedule missed or cancelled appointments as soon as possible.
Lab and Test results policy:
Routinely Dr. Quintanilla will report abnormal lab and/or test results as soon as possible, however if you do not hear form the physician's office within the time specified, you understand that you will call the office requesting those results.
Prescription Policy:
Dr. Quintanilla prefers to examine a patient before issuing a prescription. Depending on special circumstances, at times phone prescriptions are called in to the pharmacy contingent on the patient scheduling a follow-up appointment within a minimum of 72 hr; under no circumstances a prescription will be provided in patients who have not been to the office within the past 3 months.
After-Hours coverage:
Dr. Quintanilla is on call after hours for emergencies ONLY; he is not on-call for office related issues, non-emergency questions, billing issues and/or for prescription refills. These issues can be resolved during normal business hours; please have pen and paper readily available when calling the on-call physician.
Dr. Quintanilla however is not on call 24/7; he shares after-hours coverage with a group of pediatricians at Eisenhower Hospital in Rancho Mirage and with another group at Desert Hospital in Palm Springs. These pediatricians will be covering for our practice patients when Dr.Quintanilla is not on call. Keep in mind that these physicians are on-call for emergencies ONLY; they provide essential medical advice only and routinely do not call in prescriptions.
If a patient requires after-hours medical service, the practice recommends VIP Urgent Care in Rancho Mirage, (760) 674-1923, where a pediatric patient can obtain excellent medical service:VIP however closes at 9 PM and after that time the ER at either Eisenhower or Desert Hospitals is available; Dr. Quintanilla will be notified by the ER if further care is necessary.
Payment Policy
If you have insurance that you would like us to bill, we need you to bring your insurance card or insurance information with you to your appointment; without this information we cannot bill your insurance and you will be asked to pay for services rendered on your appointment day.
If you have a deductible that has not been met, we will collect 50% of the charges for that day's visit and bill your insurance. Once our claim has been processed by your insurance company, we will bill you for the balance due. All outstanding balances and co-pays are due at time of service, if you are unable to make your payment, your appointment will be re-scheduled.
If you are scheduling an "annual well exam call your insurance company and verify that this type of service is covered prior to making your appointment; if well exams are not covered by your plan, you will be required to pay for services rendered on that day.
Although we are glad to bill your insurance, remember that it is your responsibility to ensure that our claims are paid, and if or when our claims are denied you become ultimately responsible for the balance due.
Cancellation Policy:
Unexpected events happen and we will be glad to reschedule any cancelled appointment for any reason at least 24 hours advance notice. Failure to cancel an appointment at least 24 hr in advance will result in a $25 "no show" fee applied to your account. Depending on the circumstances, repeated "no show" visits may result in the termination as a patient.
Chart Copies:
It must be clearly understood that Dr. Quintanilla is the legal custodian of your children's medical records; parents are not the owners of those medical records, however they are entitled to a copy of those records if requested; the practice does not charge for the actual photocopies of the records but there is a one-time clerical fee of $35 to cover all expenses, including chart retrieval from storage, fuel surcharge, certified or regular mail expenses, and others; in addition, charts are not retrieved immediately, please make sure to request your copies with appropriate anticipation because they are retrieved and copied on a once-weekly basis; for your information California State law allows the practice a maximum of 2 weeks before producing the records.
Safety measures in the office:
Our office is designed and built according to California building code and meets state safety standards; also, we have taken extra steps to keep the office safe for your child, however in order to prevent potential accidental injuries, parents need to keep close supervision of their children inside the office and therefore follow simple safety rules, such as never leaving your child alone. not sitting on exam stools, not playing with medical equipment, not running in the premises, and other common sense supervision.
Commitment Message.
Thank You for choosing Arturo Quintanilla MD PEDIATRICS for the well being of your precious children!!....We will do our best to provide quality and competent medical services.
By signing below you understand and accept these practice policies, you agree to become responsible for payments related to medical services, and you waive all responsibility from the office of Arturo Quintanilla, MD PEDIATRICS in the event of an accidental injury inside the 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.