Physicians Quality Care

Permission to Share Information (Optional)

I authorize Physicians Quality Care to share health and billing information with the following:

Name

Relationship to Patient

Name

Relationship to Patient

HIPAA/Financial Policies *

I hereby acknowledge that I have read, understand, and agree to the terms of this document relating to HIPAA, authorization, insurance coverage, and payment for my services.

I hereby acknowledge that I have read the self-pay policy and fully understand its terms..

Patient Name *

Guardian Name

If patient is a minor

Patient's Date of Birth *

Today's Date *

NOTICE OF PRIVACY PRACTICES

We keep a record of the health care services we provide you. We will not disclose your record to others, unless you direct us to do so or unless the law authorizes or compels us to do so. You may get more information by contacting our Medical Records Department. I hereby acknowledge that I have received a copy of Physicians Quality Care’s HIPAA Notice of Privacy Practices.

FINANCIAL POLICY

Our office is committed to providing quality and cost-effective healthcare to our patients. It is essential that you understand what services are covered by your insurance plan and obtain all authorizations prior to your appointment. Your doctor may recommend services he/she feels are beneficial but may not be covered by insurance. It is your responsibility to understand the limit and restrictions affecting coverage for these services. It is your responsibility to provide us with your most current billing information. Insurance reimbursement is a contract between you and your insurance company. As a courtesy to you we file all claims for you. We will require a current copy of your insurance card in order to do this and will need to be informed of all changes in insurance status. You will be responsible for all co-pays, deductibles, co-insurance amounts along with the entire amount of any non-covered services. Payment for services is expected at the time of service

PREVENTATIVE CARE SERVICES

Your health plan may not provide benefits for preventative services. It is important you determine if your plan offers benefits for this service and their guidelines for it. We use industry standard codes and guidelines to submit insurance claims based on the encounter and documentation in the medical record. Current laws regarding fraud/abuse with billing procedures prohibit us from changing the procedure and/or diagnosis codes in order to get the claim paid by the insurance company.

BILLING POLICY

We will send a statement (to the billing address you provide) notifying you of any balances you may owe. If you have any questions or dispute the validity of any balance, it is your responsibility to contact our billing office within thirty (30) days after the receipt of the initial statement. Patient balances not paid in full within (30) days of the statement issue date are deemed past due. Past due accounts may be subject to a $5.00 monthly late fee and may be referred to a professional collection agency and/or attorney for further collection activity. If you are not able to pay the balance due in full, you must contact our billing office to discuss a payment schedule. Any late fees already incurred on past due balances will be included in any mutually agreed upon arrangements. Under administrative guidelines, if your account has been sent to collections, Physicians Quality Care will not be able to provide services for you or your family until your account has been paid in full.

Patient RegistrationHIPAA/Financial Policies