NEW PATIENT CHECKLIST
NEW PATIENT PACKET
This form is required by all new patients to fill and submit (fax or email @email@example.com ) before the first visit. It includes various forms including demographics, Medical history, Authorization for Release of Medical Information (Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility) Financial Policy (This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations) Notice of Privacy Practices (Describes how health information about you (as a patient of our practice may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
This needs to be filled in addition to new patient packet for al patients referred for evaluation and management of Diabetes
This form should be filled by all patients referred for evaluation and management of thyroid disorders or suspected thyroid disorders.
This needs to be filled by all patients in addition to New Patient Packet if they are referred for management of Osteoporosis, Calcium Disorders, Vitamin D deficiency, Kidney Stones or Parathyroid Disorders
Welcome to Capitol Endocrinology Inc.! We are pleased that you have chosen us as your health care provider. Our mission is to provide you with the highest level of professional medical care with the highest degree of patient satisfaction. To avoid any misunderstandings and ensure timely payment for services, it is important that you understand your financial responsibilities with respect to your health care.
We require all patients to sign our Authorization and Consent To Treatment Form before receiving medical services. This form confirms that you understand that the services provided are necessary and appropriate, and advises you of your financial responsibility with respect to services received.
Patients or their legal representative are ultimately responsible for all charges for services provided. We expect your payment at the time of your visit for all charges owed for that visit as well as any prior balance. Some insurance plans tell us exactly what you will owe at the time of your visit; in that case, we may request full payment for your share when you check in or out. Other insurance plans do not provide immediate information regarding patient responsibility; in that case, you will be asked to save a credit card on file to settle your account or pay a deposit when you check in or out.
If you save a credit card on file, we will charge your card for the balance due when your insurance company notifies us of your patient responsibility. When you make a deposit, you will pay an estimate of the expected patient responsibility; when your insurance company notifies us of your patient responsibility, we will either send you a statement for the balance due or issue a refund.
If you have a need or request for additional services, we may bill you for those additional services. If you are uninsured and demonstrate financial need and complete the required paperwork, financial assistance may be available. If you have a large balance, payment plans are available.
TYPES OF PAYMENTS
1. Co - payments . Insurance carriers require that we collect your co-payment at the time of your visit. If you are not prepared to make your co-payment, you may reschedule your appointment.
2. Deductibles . Most insurance plans require you to pay a predetermined amount (your “deductible”) before insurance will pay. For new patients who have not yet met their deductible, we may collect up to $125.00; for established patients, we may collect up to $75.00. This payment will be applied to your visit. When your insurance completes processing of your health insurance claim, you may be responsible for an additional amount depending on our contract with your insurer.
3. Co - insurance. Some insurance plans require that you pay a certain percentage (for example, 20%) of the allowable charge amount. Our technology allows us to view the details of your insurance plan, including your coinsurance amount, and calculate the expected out-of-pocket cost for you. If we can determine the amount, we will ask that you pay your co-insurance at the time of your visit.
4. Uninsured Patients / Self - Pay. If you do not have insurance or if the services provided are not covered by your insurance, payment for all services is due at the time of your visit.
5. Out - of - Network. We participate with most major insurance plans. It is your responsibility confirm that your provider is in your network. If we do not participate with your insurance plan, you will be required to pay for your visit at the time of service. We may send a bill to your insurance company as a courtesy. If your total charge amount is not available at the time of check out, you may be required to pay a deposit as described above.
6. Non - Covered Services . It is your responsibility to contact your insurance plan to determine whether a particular service is covered. If we provide you non-covered services, you are expected to pay for the services at the time of your visit. Our billing staff will assist you in attempting to resolve any appeals.
We ask all patients to provide their insurance card (if applicable) and proof of identification (such as a photo ID or driver’s license) at every visit. If you do not provide current proof of insurance, you may be billed as an uninsured patient (“self-pay”). If you provide your insurance card(s) at a later time, we may be able to retroactively bill the services to your insurer depending on the insurance plan’s requirements.
We accept assignment of benefits for many third party carriers, so in most cases, we will submit charges for services rendered to your insurance carrier. You are expected to pay the entire amount determined by your insurance to be the patient responsibility. Keep in mind that our fees are for physician services only; you may receive additional bills from laboratory, radiology, or other diagnostic related providers.
Know if a referral or authorization is necessary for office visits.
(If it is required and you do not have the appropriate referral or authorization, you may be billed as an uninsured patient).
Check with your insurance plan to determine if prescribed testing (lab, radiology, etc.) is covered under your insurance policy. (If you choose to have non-covered testing, we will require full payment at the time of your visit.)
Check with your insurance plan to review the schedule of benefits and whether a co-payment or deductible applies.
Fully cooperate and provide necessary assistance for us to file any appeals with your insurance plan.
Coordinate benefits if you have more than one insurance plan. You may be required to contact your insurance company to clarify which plan is primary or to correct any demographic or other issues.
Arrive for appointments with all required documentation
We will attempt to verify your insurance eligibility prior to your visit. If we are unable to confirm active insurance coverage, we will contact you about your insurance eligibility. If you are unable to provide information about other active insurance coverage prior to the visit, you will be required to either pay at the time of your visit or reschedule your appointment. For same day appointments, we will check eligibility when the appointment is made.
After your visit, we will send you a statement for any outstanding balances. We usually send out statements every twenty-eight (28) days, beginning when the balance becomes the patient’s responsibility.
All outstanding balances are due on receipt. If you come for another visit and have an outstanding balance, we will request payment for both the new visit and your outstanding balance. Your outstanding balances can be paid conveniently via our patient portal.
If you have an outstanding balance for more than ninety (90) days, you may be referred to an outside collection agency and charged a collection fee of 23% of the balance owed, or whatever amount is permitted by applicable state law, in addition to the balance owed. In addition, if you have unpaid delinquent accounts, we may discharge you as a patient and/or you may not be allowed to schedule any additional services unless special arrangements have been made.
LATE ARRIVALS, CANCELLATIONS, AND NO-SHOWS
Late Arrivals . If you arrive late for a scheduled appointment, you may be asked to reschedule your appointment or wait for an open appointment time on that day’s schedule.
Cancellations . If you are unable to keep a scheduled appointment, you must call at least one (1) business day in advance or we may consider you a “no-show.”
No - shows . If you miss your appointment, you may be charged a $50.00 fee for a missed appointment. This fee will need to be paid before you are allowed to schedule another appointment. This fee cannot be billed to insurance.
Dismissal From Practice. You may be discharged as a patient following three (3) no-shows in a one-year period (365 days).
You will be requested to provide a credit card when you check-in for your visit and we will scan the card into our system. The information will be held securely until your insurance has paid their share and notified us of any additional amount owed by you. At that time, we will notify you that your outstanding balance will be charged to your credit card five (5) days
You may call our office if you have a question about your balance. We will send you a receipt for the charge.
This “Card-on-File” program simplifies payment for you and eases the administrative burden on your provider’s office. It reduces paperwork and ultimately helps lower the cost of healthcare. Your statements will be available via your patient portal and biller is available to answer any questions about the balance due.
If you have any questions about the card-on-file payment method, please let us know.
Thank you for helping us run a better practice!