Patient Questionnaire Form (Page 3 of 3) in pdf

Winter Park Colon & Rectal Specialists, LLC

Jacqueline L. Kaiser, MD

Thank you for choosing Dr. Kaiser as your health care provider. We are committed to the success of your treatment and

believe that in the interested of an on-going, mutually satisfying doctor-patient relationship it is important to clearly state the

terms of our service. Therefore, we request that you read and sign the following Release of Medical Information and Financial

Policy prior to treatment. Minors must be authorized by the signature of a parent or guardian.

RELEASE OF MEDICAL INFORMATION

NON-COVERED SERVICES:

Please be aware that

some of the serviced provided may be considered by your

Our Notice of Privacy Practices (available in our lobby)

insurance plan to be “non-covered” or “not medically

provides information about how we may use and disclose

necessary”, therefore, you will be expected to pay for them

protected health information about you. You have the right

at the time of service. An ANOSCOPY may be performed

to review our notice before signing this consent.

as part of your examination.

Some insurance plans

provided in our Notice, this organization originates and

consider this a surgical procedure and may charge this

towards your deductible.

maintains health records describing your health history,

symptoms, examination and test results, diagnoses,

NON-PARTICIPATING COMPANIES:

Your insurance

treatment and any plans for future care of treatment. You

have the right to request that we restrict how protected

policy is a contract between you and your insurance

health information about you is used or disclosed for

company. Dr. Kaiser is not a party to that contract. You

treatment, payment or healthcare operations. We are not

are responsible for payment in full for charges incurred at

required to agree to this restriction but if we do we are

the time of service. We charge what is reasonable and

bound by our agreement. By signing this form, you are

customary for our area based on the Health Care

consenting to the use and disclosure of protected health

Financing Administration. You can file a claim to your

information about you for treatment, payment and other

insurance company for reimbursement at their non-

health care operations. You have the right to revoke this

participating rate.

consent, in writing, except to the extent that our

organization has already taken action in reliance thereon.

MISSED APPOINTMENTS:

We realize your time is

valuable and that long delays in the schedule are

FINANCIAL POLICY

unacceptable so we do our best to schedule carefully. It

is very important that you give us 24 hours notice when

We will file your insurance for you, however, it is your

you are not able to make your appointment. We reserve

responsibility to verify your own insurance benefits and

the right to charge a $25 fee for any missed office

notify us of any changes. Ultimately, payment for services

appointments and an additional fee of $100 for any missed

is the responsibility of the patient or guarantor.

surgical appointments, including but not limited to

colonoscopy,

sigmoidoscopy

and

office

surgical

PAYMENT, CO-PAYMENT, PERCENTAGES AND OR

procedures.

DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE.

We accept cash, checks, Visa, Master Card, Discover and

OTHER FEES: We charge $30 for any check that is

American Express.

returned for nonsufficient funds.

If your account is

assigned to an outside collection agency you agree to

PPO/MEDICARE:

As a participating provider we are

reimburse us an additional fee of 30-50% of the debt and

contractually

required

collect

co-payments,

all expenses, including reasonable attorneys’ fees, we

percentages and deductibles at the time of service. If your

incur in such collection efforts.

insurance company has not paid your account in full within

45 days you will be responsible for payment.

HMO:

As a participating provider we are contractually

My signature below confirms my understanding and

required to collect co-payments, percentages and

agreement to the above Release of Medical Information

deductibles at the time of service. It is the patient’s

and Financial Policy.

responsibility to ensure that Jacqueline L. Kaiser, MD

and/or VitalMD is a participating provider in your health

plan and to have a referral from your primary care

physician prior to your appointment(s). Please check to

Patient Signature

Date

make sure the referral includes an authorization number,

number of visits approved and an expiration date. By

contract we are unable to see you without this.

_____________________________________________

Patient Questionnaire Form Page 3

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