NEW PATIENT CHECKLIST
NEW PATIENT FORMS
This form is required by all new patients to fill and submit (fax or email @ ) 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.
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
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.
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.
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.
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.
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.
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.