Thank
you for choosing
Please
review the information below and sign where indicated.
PATIENT NAME:___________________________________________________________
Is your child either an American Indian or
Alaska Native: Y / N
Financial
Responsibility:
Patients must arrive at their scheduled
appointment with their insurance card, photo ID and insurance copay if
applicable. Copays required by a
patient’s insurance plan must be paid at the time of the appointment.
When your child is scheduled for a WELL PATIENT EXAM, it will be billed as
such to your insurance plan. Insurance
companies may refer to this as PREVENTATIVE
CARE or ROUTINE EXAM. Due to coding
laws, we MUST bill your WELL PATIENT EXAM as Preventative Care. If, during your visit you have ADDITIONAL
CONCERNS or PROBLEMS that require a diagnosis and/or other treatment, it may be
considered a Problem Oriented Exam and you may incur additional office or lab
charges. These charges and any from your
Preventative Care Exam will be billed to your insurance company. You and your physician may want to keep your
Well Exam separate from your Problem Oriented Exam and we would be happy to
schedule it that way for you. If your
insurance company does not cover some or all of these charges, you will be
billed directly for the balance they indicate as “patient responsibility”.
Your child’s Well Exam is important whether
it is a covered benefit or not. Please
take the time to make yourself familiar with your insurance benefits. Feel free to call the insurance company and
ask about coverage. There are many plans
and your benefits can change often.
NOTE: Certain
tests we order as part of your Well Patient Exam may or may not be covered by
your insurance. This includes, but is
not limited to: blood work, lab tests, immunizations, audiometry (hearing
test), and x-rays.
Late Cancellation
and No Show Fee Policy:
A late cancellation or no
show fee of $25 will be charged to all patients who do not provide 24 hour
notification to cancel a scheduled appointment or for patients who miss or no
show their scheduled appointment.
Health Insurance
Portability and Accountability Act (HIPAA):
I understand NSP will use and
disclose health information about the patient in compliance with the HIPAA
Act. I understand I am entitled to
receive a copy of the Notice of Privacy Practices as outlined by Federal
Regulations. I have the right to ask that
some or all of the patient’s health information may not be used or disclosed in
the manner described in the Notice of Privacy Practices. I also understand NSP is not required by law
to agree to such requests. My signature
below acknowledges I am aware of my rights in accordance to HIPAA.
Release of Information and Benefits:
I authorize my insurance
benefits be paid directly to the physician.
I am responsible for any co-payments, deductibles, balances due, and
charges for services not covered by my insurance plan. I authorize the physician or insurance
company to release any information required for processing of insurance
claims. This authorization is in effect
until rescinded.
Signature_________________________________________________Date_________________________
We keep a record of the
health care services we provide your child.
You may ask us to see and copy that record (copy charges may
apply). You may also ask us to correct
that record. We will not disclose your
child’s record to others unless you direct us to do so or unless the law
authorizes or compels us to do so. Contact the Record’s Custodian to see the
record or to get more information about it.
I,______________________________,
the parent or legal guardian of,_______________________ authorize and consent
to routine and emergency medical treatment for my child when deemed necessary
by qualified medical personnel. This
authorization will be in effect until revoked in writing by me.
I acknowledge that I have read and understand the information
above. I understand I will be
financially responsible for services that my insurance company indicates are
“patient responsibility”.
________________________________________________ ______________
Patient/Parent/Guardian
Signature
Date