NAME: ADDRESS: CITY: STATE: ZIP: SS#: HOME PHONE: WORK PHONE: EMAIL ADDRESS: NAME: PHONE: NAME: PHONE: NAME: PHONE: RESPONSIBLE PARTY (COMPLETE IF RESPONSIBLE PARTY IS OTHER THAN THE INSURED OR PATIENT) NAME: ADDRESS: CITY/STATE/ZIP: SS#: NAME OF INSURED: RELATION TO PATIENT: INSURANCE COMPANY: ID: INSURANCE PHONE: GROUP: INSURED DATE OF BIRTH: SS#: SECONDARY INSURANCE (IF APPLICABLE) NAME OF INSURED: RELATION TO PATIENT: INSURANCE COMPANY: ID: INSURANCE PHONE: GROUP: INSURED DATE OF BIRTH: PATIENT/RESPONSIBLE PARTY SIGNATURE: DATE: GHPMA THE WOODLANDS FAMILY MEDICINE DATE OF BIRTH: SEX: [M] [F] MARITAL STATUS: [ ] MARRIED [ ] SINGLE PATIENT INFORMATION PRIMARY INSURANCE I UNDERSTAND THAT THIS FORM MUST BE COMPLETED IN ITS ENTIRETY. I UNDERSTAND THAT IF ALL OF THE ABOVE INFORMATION IS NOT COMPLETED, A CLAIM MAY NOT BE ABLE TO BE FILED TO MY INSURANCE COMPANY; THEREFORE, MAKING ME FULLY RESPONSIBLE FOR ANY CHARGES INCURRED. CELL PHONE: DATE OF BIRTH: PREFERRED PHARMACY: (PLEASE LIST RELATION) EMERGENCY CONTACT
Transcript
NAME:
ADDRESS:
CITY: STATE: ZIP: SS#:
HOME PHONE:
WORK PHONE:
EMAIL ADDRESS:
NAME: PHONE:
NAME: PHONE:
NAME: PHONE:
RESPONSIBLE PARTY (COMPLETE IF RESPONSIBLE PARTY IS OTHER THAN THE INSURED OR PATIENT)
NAME:
ADDRESS:
CITY/STATE/ZIP: SS#:
NAME OF INSURED: RELATION TO PATIENT:
INSURANCE COMPANY: ID:
INSURANCE PHONE: GROUP:
INSURED DATE OF BIRTH: SS#:
SECONDARY INSURANCE (IF APPLICABLE)
NAME OF INSURED: RELATION TO PATIENT:
INSURANCE COMPANY: ID:
INSURANCE PHONE: GROUP:
INSURED DATE OF BIRTH:
PATIENT/RESPONSIBLE PARTY SIGNATURE: DATE:
GHPMA
THE WOODLANDS FAMILY MEDICINE
DATE OF BIRTH:
SEX: [M] [F]
MARITAL STATUS: [ ] MARRIED [ ] SINGLE
PATIENT INFORMATION
PRIMARY INSURANCE
I UNDERSTAND THAT THIS FORM MUST BE COMPLETED IN ITS ENTIRETY. I UNDERSTAND THAT IF ALL OF THE
ABOVE INFORMATION IS NOT COMPLETED, A CLAIM MAY NOT BE ABLE TO BE FILED TO MY INSURANCE
COMPANY; THEREFORE, MAKING ME FULLY RESPONSIBLE FOR ANY CHARGES INCURRED.
CELL PHONE:
DATE OF BIRTH:
PREFERRED PHARMACY:
(PLEASE LIST RELATION)
EMERGENCY CONTACT
Patient History Form
Patient name:_____________________________ Date:_____________________________________ Medications Please list all medications that you're currently taking, prescription and nonprescription, and their dosage: Medication Dose Allergies ___________________________ ____________ Are you allergic to any medications? ___________________________ ____________ YES NO ___________________________ ____________ ___________________________ ____________ If yes, please list the name of the medication the
type of reaction: ___________________________ ____________ ___________________________ ____________ _____________________________________________________________________ ____________ _____________________________________________________________________ ____________ _____________________________________________________________________ ____________ Are you allergic to any foods? ___________________________ ____________ YES NO ___________________________ ____________ If yes, please list:____________________________
Past Medical History Please indicate if you have ever experienced any of the following conditions: Alcohol dependence Headache Allergies Heart attack Anemia High blood pressure Angina High cholesterol Anxiety Irregular heartbeat Arthritis Insomnia Asthma Irritable bowel syndrome Blood clots Hepatitis Broken bones Kidney stones Cancer Liver disease Type:____________________ Low blood pressure Chronic blood thinner use Migraines Chronic bronchitis Osteoporosis Chronic sinusitis Palpitations Congestive heart failure Seizure/epilepsy COPD/emphysema Sleep apnea Depression Stomach ulcer Diabetes type I Stroke or TIA Diabetes type II Thyroid disease Esophageal reflux Tinnitus Gallbladder stones Tuberculosis Gout Other:____________________
Surgical History Please check all that apply and the date of the procedure: Date Date Angioplasty ___ /___ /___ Gastric bypass ___ /___ /___ Angioplasty with stent ___ /___ /___ Hernia repair ___ /___ /___ Appendectomy ___ /___ /___ Hip replacement ___ /___ /___ Back surgery ___ /___ /___ Knee replacement ___ /___ /___ Carpal tunnel release ___ /___ /___ Liver biopsy ___ /___ /___ Cataract extraction ___ /___ /___ Pacemaker ___ /___ /___ Colon surgery ___ /___ /___ Thyroidectomy ___ /___ /___ Coronary artery bypass graft ___ /___ /___ Tonsillectomy ___ /___ /___ Gallbladder ___ /___ /___ Other: ____________ ___ /___ /___
Female Surgical History Male Surgical History Please check all that apply: Please check all that apply: Date Date Breast implants ___ /___ /___ Prostate biopsy ___ /___ /___ Bilateral tubal ligation ___ /___ /___ TURP (transurethral
Family History Please check if any family member has had any of the following conditions and indicate the name of the affected member, the age of onset and/or if it was the cause of death. Adopted
Mother Father Sibling(s) Children Grandparents Cause of death
Alcoholism
Alzheimer's
Heart disease
Cancer
Type:______
Depression
Diabetes
High blood pressure
High cholesterol
Kidney disease
Osteoporosis
Stroke
Seizures
Social History Type of employment________________________ Previous work, if retired__________________________
Marital Status Married Single Divorced Widowed
Do you currently use tobacco? Yes No If yes, how many packs per day? ____________
Have you previously smoked? Yes No If yes, how many packs per day? ____________
Other tobacco units per day (dip, cigars, etc.)?
Units per day? __________ Years used? __________ Year quit? __________
Do you drink caffeine? Yes No Type? ___________ Amount Daily? _____________
Do you drink alcohol? Yes No Daily Weekly Monthly Amount:__________
Religious preference (optional)_________________________________
Immunizations Are your immunizations current? Yes No Do you have copies of your immunization records? Yes No
Pharmacy Information Do you have a preferred pharmacy? Yes No
Are you interested in any cosmetic products or procedures to decrease aging of the skin (wrinkles, fine lines, age spots, melasma, acne etc.)? Yes No
DISCLOSURE OF FINANCIAL INTEREST
832-813-8613
THE WOODLANDS, TX 77380
SUITE 130
1011 MEDICAL PLAZA DRIVE
WILSON IMAGING
THE WOODLANDS, TX 77381
SUITE 150
4800 WEST PANTHER CREEK
THE WOODLANDS OPEN MRI AND IMAGING
281-257-2920
SPRING, TX 77379
6225 FM 2920 ROAD
2920 OPEN MRI AND DIGITAL IMAGING
GHPMA PLLC, WITH WHICH YOUR PHYSICIAN HAS A FINANCIAL RELATIONSHIP, OPERATES
DIAGNOSTIC/IMAGING CENTERS IN WHICH YOU CAN RECEIVE THE DIAGNOSTIC/IMAGING SERVICE(S)
ORDERED FOR YOU. YOU CAN ALSO RECEIVE DIAGNOSITC SERVICE(S) AT THE FOLLOWING FACILITIES:
SUITE 100
1733 WOODSTEAD CT
WOODSTEAD MRI
281-367-6736
WE WILL BE SETTING UP THE TEST AT OUR DIAGNOSTIC CENTER HERE IN THE BUILDING. PLEASE
NOTIFY US IF YOU WISH TO HAVE IT AT ANOTHER FACILITY.
PATIENT/RESPONSIBLE PARTY SIGNATURE DATE
281-364-8840
THE WOODLANDS, TX 77380
832-381-3800
THE WOODLANDS, TX 77380
SUITE 190
8850 SIX PINES DRIVE
WOODLANDS IMAGING
Brent Allmon, M.D. Woodlands Family Medicine 17521 St. Luke's Way, Suite 190 The Woodlands, Texas. 77384
Phone: 281-719-5450 Fax: 936-321-4469
NEW POLICY REGARDING MISSED APPOINTMENTS
Effective Jan. 1, 2014
We are dedicated to helping our patients and appreciate those who value this dedication of time, energy and service. We received many calls from patients who wish to be seen on the same day. Our schedule is often full. Last minute cancellations and no-shows adversely affect other patients. Therefore, effective Jan. 1, 2014:
• All no-show/missed appointments will result in a fee of $50.
• The same $50 fee will also apply to patients who do not give us at least a 24-hour cancellation notice.
Your understanding and cooperation is appreciated. Dr. Brent Allmon, M.D. Dr. Alice Grogan, M.D. Dr. Joel Kerschenbaum, M.D. Patient signature__________________________ Date___________________________
Currently, our office receives a large-volume of calls and faxes daily for medication refill requests. Our office can no longer safely manage this volume of phone and fax requests. As of September 10, 2012, we have a new prescription refill policy. We understand that this is a change for both you and us. We hope to work together to ensure safe, efficient and high-quality medical care. Thank you for being our valued patient!
It is typically my practice to give prescriptions with refills for 6 months at a time to coincide with six-month followup appointments for monitoring. It is very important to request your prescriptions during your routine office visits. In order to ensure that you do not run out of your medications, please make sure to schedule a followup appointment at the end of each visit. If office visits are scheduled and kept on a regular basis, prescriptions are refilled at these visits, and pharmacies follow instructions on prescriptions given, then requests for refills outside of office visits should rarely occur.
As of September 10, 2012, requests made for prescription refills made outside of an office visit may be subject to a fee:
1. $15.00 may be charged for 1-3 prescription refills that or not requested during an office visit
2. $25.00 may be charged for 4+ prescription refills that are not requested during an office visit.
To request a refill, please leave a detailed message on our refill request voicemail. Please allow 2 business days for refill requests to be completed.
Ways to reduce unnecessary refill requests and medication errors:
1. We do require office visits on a regular basis for all of our patients taking prescription medication. The interval for followup will vary depending on the type of medication you are prescribed. Please be sure you have enough medication to last until your next scheduled visit.
2. Before you come to your regular appointment, you should look over your medications, diabetic supplies, inhalers etc. to determine if you need to request any new prescriptions at your appointment.
3. Please bring all of your prescription bottles with you to your appointment. This is important to make sure that you're taking the correct medications in the correct dosages. We will to take the time to carefully review your medications and write for refills at your office visit.
4. It is your responsibility to schedule a followup appointment before you run out of your medication. We recommend you schedule your next visit before you leave our office.
5. If you are changing pharmacies, you can usually have your new pharmacy request prescriptions be transferred from your old pharmacy.
“Auto-Renewal”, “Auto-Fax”, “Readyfill” etc.
Most of the requests for refills that we receive are generated automatically from the pharmacy without the patient's knowledge. "Auto-renewal" or "Auto-Fax" programs with most pharmacies are at fault for most of these requests. As of March 15, 2013, we will no longer respond to refill requests that are faxed from the pharmacy. If you are in need of a refill we expect you to contact us directly and leave a detailed message on our Refill Request Voicemail.
Reasoning:
From my research, the main benefit for "auto renewal" is for the pharmacy. This generates a constant stream of cash flow for pharmacies and often does not benefit the patient. It is my experience that when we receive "Auto-renewal" refill requests from the pharmacy, the patient usually still has medication and is not actually in need of refill. In many cases, the pharmacy is requesting a refill on behalf of the patient without their knowledge and may be billing insurance for the medication regardless of whether the prescription was picked up by the patient. Refilling prescriptions without a patient's approval raises the possibility of insurance fraud, state officials say. According to the L.A. Times, one national pharmacy chain is under federal investigation for this very reason.
“Auto Renewal” also increases chance for medication errors. Consider this common example:
“In the past few weeks we heard from a patient utilizing the automatic refill system who picked up three prescriptions but later called the pharmacy to report he had picked up a blood pressure pill called Norvasc, which his doctor had previously discontinued. Fortunately, he hadn’t yet taken any. In another case a patient’s Cardizem, a heart medication, was increased from 240 mg to 360 mg. The elderly gentleman purchased the new prescription for diltiazem 360 mg but also received the diltiazem 240 mg prescription that had been filled earlier through the automatic refill program. After receiving a call from the confused patient, the pharmacist contacted the patient’s doctor to determine which strength the patient should be receiving. Had the patient accidentally taken both strengths of Cardizem, it could have caused serious heart or blood pressure complications.”
Acknowledgement of Receipt:
Patient Signature ______________________________ Date _______________________
Woodlands Family Medicine Discontinues Patient Statements (Bills) Dear Patients, You will no longer receive bills from our office in the mail. We have discontinued sending patient statements. We now require a credit card on file with our office. Why the change? There are several reasons. First, statements are wasteful of paper, stamps, and envelopes. Second, we need to ensure that we have a guarantee of payment on file in our office. Things are changing in healthcare, and we need to be sure that patient responsible balances are paid in a timely manner. But I always pay my bills, why me? We have to be fair and apply the policy to all patients. We have wonderful patients and we know that most of you pay your balances. Unfortunately, this is not the case every time. How will I know how much you are going to charge me? You will receive a letter in the mail from your Insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits, or EOB. This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay. Then what? We receive the same letter that you do. It arrives about 20 – 30 days after your appointment. We look at each Explanation of Benefits (EOB) carefully, and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a bill for in the mail. But wait, I’m nervous about leaving you my credit card. We do not store your sensitive credit card information in our office. We store it on a secure website called a gateway. We access your information only on this site to process a payment. What if I need to dispute my bill? We will always work with you to understand if there has been a mistake, and we will refund you if we have made a billing error. We will only charge the amount that we are instructed to by your insurance carrier, in the letter they send to us, in the same way that we normally determine how much to send you a bill for in the mail.
What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if the policy has a $500 deductible, you must pay the first $500 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does.
When does a deductible begin? Your deductible begins at the start of your plan year. Most plan years begin either January 1 or July 1, but plans can start on any date. (The Medicare plan year begins January 1 and the deductible is $147 for 2014.)
When do I have to pay for services? Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met. If you have a very large deductible, called a high-deductible insurance plan, you may have to pay out of pocket for most of your primary care services. How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible. Will you send me a bill to let me know what I owe? Woodlands Family Medicine will not send patient statements, which is one way we keep costs down. All patients are required to keep a credit card on file, but we do not charge anything to your card without your approval. You will receive notice of any amount charged to your card. What if I have more questions? Our staff is happy to speak with you about your account at any time.
Policy for Guarding Patient Credit Card Information Issue Date: 11/14/13 Reviewed: 11/14/13 Policy Statement All card processing activities and related technologies must comply with the Payment Card Industry Data Security Standard (PCI-DSS) in its entirety. Card processing activities must be conducted as described herein. No activity may be conducted nor any technology employed that might obstruct compliance with any portion of the PCI-DSS. This policy shall be reviewed at least annually and updated as needed to reflect changes to business objectives or the risk environment. Applicability and Availability This policy applies to all employees: full-time and part-time, temporary and permanent, residents and medical students, volunteers, contractors and consultants who are “resident” on site. Configuration standards must be maintained for applications, network components, critical servers, and wireless access points. Configuration standards must include:
• Updating of all anti-virus software and definitions • Provision for installation of all relevant new security patches within one month • Prohibition of group and shared passwords
Distribution, maintenance, and storage of media containing cardholder data must be controlled, including that distributed to individuals. Procedures must include periodic media inventories in order to validate the effectiveness of these controls. Procedures for data retention and disposal are as follows:
• Media containing credit card information (paper record) shall be cross-cut shred just as soon as it has been entered into the secure gateway system.
Unencrypted Primary Account Numbers may not be sent via email. Procedures for data control must be maintained and incorporate the following:
• Access rights to privileged User IDs are restricted to least privileges necessary to perform job responsibilities
• Assignment of privileges is based on individual personnel’s job classification and function • Automatic disconnect of remote access technology sessions (Gateway) after a specific period of
inactivity • Prohibition of the storage of cardholder data onto local hard drives and removable electronic media
when accessing such data via remote access technologies • Prohibition of copy, move, storage and print functions during remote access
Woodlands Family Medicine
Payment Plan Agreement Today’s Date ______________________ Patient Name ____________________________________ DOB: __________________ Amount to be paid via payment plan $________________ Payments will be made as follows:
Amount of Payment: $_________
Made at this interval __________________ (monthly, biweekly, every 30 days) until paid in full. Default on this plan through a denied credit card or by challenging the transaction without payment in full of this debt without prior communication with _______________________(practice employee) at this number _________________will result in dismissal from the practice and turning the account over to a third-party collection agency. I agree to pay for the services I received from ____________________________(practice name) as indicated below. All payments will be made by my credit card on file. _______________________________ __________________ Patient Signature ________________________Date _______________________________ __________________ Practice Employee Signature as Witness Date
Authorization for Credit Card On File Payment
NOTE: Your credit card information is not kept on file in this office. It is kept securely offsite and this office does not have access to the full credit card number once it is entered into the system the first time.
AUTHORIZATION
Until further notice, I authorize __________________________to charge the patient-responsible balances on my account to the following credit card:
Circle one: Visa Mastercard Discover
Last 4 digits of my credit card: ____ ____ ____ ____
Email, if you would like an email receipt:___________________
WOODLANDS FAMILY MEDICINE FINANCIAL POLICY
We require all patients to pay at time of service by credit card on file. You will be charged at every visit for any outstanding deductible, co-insurance or co-pay due, as well as any fees for services not covered by your insurance plan.
Your Plan What You Do What We Do Medicare Pay your deductible ($147 for 2014) and co-
insurance (20% of the allowable.) If you request any services that Medicare does not cover, you agree in writing to pay our regular fee for those services.
We will file Medicare for you.
Medicare + Secondary Insurance
No payment due at time of service. We will file Medicare and your secondary insurance for you.
Commercial Insurance Pay your deductible, co-insurance or co-pay at time of service.
We will file your insurance for you.
Insurance we are not contracted with
Pay the visit in full at time of service. We will provide a receipt for your services for you to file with your insurance for reimbursement.
Health Savings Account (HSA)
Your HSA credit card must be on file. We will file your insurance and if the amount due is not paid via your HSA, we will charge your HSA credit/debit card on file.
Additional Charges:
• No Show: $50 • Completion of Forms: $25 to $50, based on time • Out of office prescription refills: $15 to $25 • Prior Authorization for medication
(if required by your insurance): $25
FINANCIAL POLICY FOR WOODLANDS FAMILY MEDICINE AGREEMENT TO PAYMENT POLICY I acknowledge that I received a copy of Woodlands Family Medicine financial policy and agree to the terms of payment due. ASSIGNMENT OF BENEFITS I hereby request that payment of authorized Medicare, Medicaid and all other insurance benefits be made on my behalf to Woodlands Family Medicine/GHPMA for any services provided to me and/or my dependents. I authorize any holder of medical information about me and/or my dependents to release to the appropriate entity and its agents any information needed to determine these benefits payable for related services. GUARANTEE OF PAYMENT If my insurance has a contract with Woodlands Family Medicine/GHPMA I am not responsible for amounts that have been agreed to write-off. Otherwise, I agree that I am responsible for services provided that are not paid by my insurance. If my insurance does not have a contract with Woodlands Family Medicine/GHPMA, I agree to be responsible for any services provided. In the event that I default on payment of my account, I understand I am responsible for any and all costs incurred on the collection of my account, including court costs and reasonable attorney’s fee. If the debt is assigned to a third party collection agency, I agree to be responsible for collection fees and interest due to amounts in default. Failure to pay any outstanding debt may be considered cause for dismissal from Woodlands Family Medicine/GHPMA. ACKNOWLEDGEMENT OF RECEIPT OF POLICY FOR GUARDING PATIENT CREDIT CARD INFORMATION I hereby acknowledge that I have received and had an opportunity to ask questions concerning the Woodlands Family Medicine Policy for Guarding Patient Credit Card Information. _____________________________________ _____________________________________ Patient’s Name Printed Patient’s Date of Birth _____________________________________ _____________________________________ Patient’s Signature Date ______________________________________ _____________________________________ Responsible Party Signature Relationship to Patient
