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\n \r #$ %& ' \n (\n !))\n \n )$ !$ '! *+,#-!% (' ! ( !' !' !)$ !$ ! ! \n*+-. / +! +! \n ) \n!' ' ) \n \n( $(\n \n!))\n \n( \n.#$! $ &$ 0$ / +! +! \n \n&&$\n \n . \n \n$ &$ \n \n/ +! +! \n!!' .1 \n )/ +! +! \n'!% %! )% 0!)&!0 2( \n \n\n \r 3( 4 )!.5$$\n \n '! !'$ ' ! ! ! !) ! !' \n\n!& '! \n ! '\n$!!\n\n\n$ ! !& (+\n( $!\n! ' ') \n\n(! '\n!)! !\n !& ' ! ! ()&!% ! \n(\n!' & $ \n.5$$\n \n '!)\n (\n\n'' ) ! )\n0$ /!' 66666666666666666666666667 ! \n$ 66666666666666666 $ 66666666666666666/!' 66666666666666666666666667 ! \n$ 66666666666666666 $ 66666666666666666/!' 66666666666666666666666667 ! \n$ 66666666666666666 $ 666666666666666665$$\n \n '!'! '$ ' $ ! ! ! ! '\n$!!\n\n\n$ ! !& (+\n( $!\n! ' ') !)\n!)! \n! ' \n!\n &!\n$ ! '!\r )+ \n !!) ) !.5$$\n \n '! '! '$ ' $ ! ! ! ! '\n$!!\n\n\n$ ! !& (+\n( $!\n! ' ') !)\n!)! \n! ' \n.#$! $ &$ 2( \n$! \n $ 0(\n \n )\n \n \n'+,# ! (+., 0 $ ! \n 2( ) !& ' 2( \n ) \n \n%( ) \n\n% ()%$\n!& ' . \n&&$\n '#!' \n & (\n !))\n \n( '+,# ! (+.#'! \r ' \n 0& " $ " $!$ ! $!\n! !)'!) )\n \n( \n ! ( ' \n .# #) \n&$\n \n ! \r '!) ) !' ' . \n\n\n \n \r \n \n ! "\n \n #\n!$" % \r\n \n #\n!$" % Rev 9/2013 Trinity Family Physicians Financial and Insurance Policy Thank you for choosing Trinity Family Physicians as your health care provider. As part of our se rvices, we require you read and sign the following financial policy prior to services being rendered. Patient or responsible party must complete our information and i nsurance form before seeing our physicians or nurse practi ti oner. * Payments: F ull payment, co - payment, co - insurances and / or deductibles are due at the time services are rendered. Payment methods are: Cash, Check, and credit card. If you do not have your fees with you at the time of services we have the right to reschedule your app ointment . Please bring yo ur insurance card, driver's license and your portion to pay with y ou at every visit . If your account becomes delinquent requiring a referral to collections the n you will be responsible for all fees incurred . ________Initials *Return checks: A $35.00 service charge will be charged to your account for returned checks. Returned checks will not be re - deposited. All balances must be paid in cash or by credit card. One attempt will be made to colle ct this debt fro m the patient, if not collected within 5 days of the returned check; the account will be turned over to a collection agency. We request a copy of your driver's lice nse for our records for verification. ________Initials *Office Policy: Per our contract with ea ch insurance policy, it is your responsibility to know your benefits. Insurance is billed as a courtesy to our patients; however, the patient is the final responsible part y. Your insurance company does no t guarantee your benefits until the claim is filed. If your insurance has not paid within 60 days you will be responsible for the balance. Your insurance will send you an explanation of benefits that explains what they have paid to our office. If you do not agree with their payment, ple ase contact the insur ance compa ny directly. ________Initials *Appointment Cancellation Policy: A $35.00 fee will be charged for scheduled appointments can
13 celled without 24 hours prior notice
celled without 24 hours prior notice or if you walk out prior to being se en. Patient will also be charged for f ailure to show up for a scheduled appointment . If you have more than two missed no show appointments you may be dismissed from our practice. ________Initials *Minor Patients (under the age of 18): The adult accompanying a minor (patient/guardian) is responsible for full payment at the time of service. For unaccompanied minors, payment arrangements need to be made in ADVANCE and we must have parents or guardians written permission along with a copy of their photo I.D. prior to treatment of a minor. ________Initials *All Medicare Patients: We will bill Medicare as well as secondary insurance. If you have Medicaid as a secondary insurance we will not b e able to see you. If payment is not received from your secondary insurance within 60 days, you will be notified that there i s an outstanding balance due. You must then contact your secondary insurance to receive reimbursement for any fees paid directly to our office. _______Initials *PCP Selection: It is your responsibility to make sure that if your insurance requires a PCP to be selected on your insurance policy that you have it switched over to one of our providers prior to your initial visit and make sure our provider is the effective and current provider for you . If this is not done or not effective prior to your appointment you understand that you will be financially responsible for that v isit at the time of service. This is your insurance company’s policy and not ours. _______ Initials *Policy on Physical Exams: We do encourage physicals (well - visits) at separate visits during the month of your birthday each year. We recommend all patients to do this f or preventative care and health maintenance. If you are here for a medical complaint then this visit is NOT a physical and will be billed accordingly. _______Initials Please realize that: 1. Your insurance is a contra ct between you, your employer and the insurance company. 2. You are responsible for all charges that are denied / not covered by your insurance company. Procedures / services performed by our physicians, nurse practi ti oner or nurses may not be covered under your insurance plan. 3 . Although we verify your coverage through your insurance company with each and every patient, verification of benefits is no t a guarantee of payment from your insurance company. We request that you present a copy of your ins urance card for our reco rds that is being utilized. 4. If you are sent outside of the office for additional testing such as lab work or imaging, that facility will file your insurance for you. If you have q uestions regarding billing or claim payment, call the facility directly. We do not have information regarding billing from outside this office. Print Patient's Name: ____________ ______________________________________ ___ __ Date: ___________________ ____ __________ __ Signatur e of Patient or Legal Guardian: ____________________________________________________________________________ ____ _ Print Name of Parent / Legal Guardian: _______________________________________________________________________________ __ Initials Trinity Family Physicians Let Our Family Care for Yours Medication List for: Please list your current medications: Currently, I am NOT on any medication. NameStrengthCap/Tab/Other?Frequency 1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________ 4. _____________________________________________________________________ 5. _____________________________________________________________________ 6. _____________________________________________________________________ 7. _____________________________________________________________________ 8. _____________________________________________________________________ 9. _____________________________________________________________________ 10. 11. 12. ____________________________________________________________________ Trinity Family Physicians Let Our Family Care for Yours Initials Name: _________________________________ Initials OTHER: _______________________________________________________________________________ NONE OF THE ABOVE Name: _________________________________ Initials Name: _________________________________ Initials Name: _________________________________ Initials
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