Patient Registration & Insurance Information Form Page 2
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2Authorizations and Acknowledgments
We are committed to providing you with the best possible care, and we are pleased to discuss our professional
fees with you at any time. Please ask us if you have any questions about our fees, financial policy, or your
payment responsibility.
All new patients will be asked to provide patient information prior to being seen by the physician. We also may
ask to make a copy of any type of picture identification to remain a permanent part of your chart.
Insurance
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If you are covered by Medicare,Tricare or any of our managed plans, we will file your insurance claim. You
Information
are responsible for any co-pay, co-insurance, deductible, or non-covered services at the time of your visit. If
we do not participate with your insurance company, you will be responsible for full payment at the time of
your visit. Methods of Payment: Cash, Check, Visa, Mastercard and Discover.
All self-pay patients are expected to pay for services in full at the time that services are rendered.
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We will file with all insurance plans for our professional fees for any hospital admissions.
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In the event your insurance company does not pay the full balance within 90 days, we will notify you so that you
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may contact your insurance carrier. Please remember that ultimately, payment responsibility rests with the patient.
Please advise the office personnel of any changes in your insurance or mailing address.
•
•
Should it ever become necessary to use the services of a collection agency to collect your account, you would
be responsible for any costs incurred for that purpose.
Worker’s
Worker’s Compensation patients will be seen only after the proper authorization and paperwork has been received.
Compensation
Unaccompanied
The parents (or guardians) will be responsible for full payment unless covered by a participating managed plan.
Minors
Authorization to treat an unaccompanied minor must be on file.
Completion of
Baptist Health reserves the right to charge a nominal fee for the completion of disability and/or Family Medical
Forms
Leave forms.
Authorization
I consent to examination,diagnosis and general medical care and treatment to be performed by office personnel,
for Treatment and
including physicians, nurses and assistants.
Payment
I hereby authorize Baptist Health to bill my insurance company directly for these services. I understand I am
financially responsible for charges not covered by my insurance company. I authorized any holder of medical or
other information about me to release to the Social Security Administration or intermediaries any information needed
for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and
request payment of medical benefits either to myself or to the party who accepts assignment. I certify that the above
information is currently correct.
_________________________________________________________________ ________________________________________
Responsible Party Signature
Date
_________________________________________________________________ ________________________________________
Patient’s Name (Please Print))
Date of Birth
Notice of Privacy
I acknowledge receipt of a copy of the Baptist Health Notice of Privacy Practices (NPP) either at this time or
Practices
previously. By accepting services at Baptist Health, I authorize Baptist Health to use and disclose information from
and release copies of my (the patient’s) medical records in accordance with Baptist Health’s policies and privacy
practices, which are summarized in the NPP, including disclosure to my (the patient’s) past, present and future
healthcare providers.
_________________________________________________________ ____________________________________
Patient or Parent (Guardian)
Date
07/2015
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