Office Policy And Authorizations Form - Tlc Form

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10205 W. Hillsborough Ave., Suite B, Tampa, Florida 33615
Phone: 813.884.2300 • Fax: 813.884.2390
11357 Countryway Boulevard, Tampa, Florida 33626
Phone: 813.925.8800 • Fax: 813.925.8840
Office Policy and Authorizations Form
The following policies help us to ensure that we give the best care to each of our patients. We have only your best interests at
heart, therefore, if you have questions regarding a certain policy, please do not hesitate to ask.
u 24 hour notice is required for cancellation of appointments. There is a $25.00 fee for all missed
appointments not cancelled 24 hours in advance.
u All new patients are required to bring a driver’s license (picture ID) and insurance card (if applicable)
with them at time of visit. Policy numbers and policy information will not be accepted as a substitute
for the card.
u You MUST have your insurance card (if applicable) with you at each visit. Office staff has the right to
request you to present your insurance card at any time.
u Co-payment is due at time of visit.
u Past due balances are due at time of visit. If for any reason you are unable to make payment at the time
of your visit, a credit card authorization form MUST be completed and kept on file.
u No personal checks please*. All major credit cards accepted.
u A $10.00 charge on all delinquent accounts turned over to the collection agency; and a finance charge
of 1.5% monthly on all past due accounts.
u Please allow 48 hours for all refill requests to be processed. Refills requested on a Friday will not be
processed until the following Monday. Refill of prescriptions is at the discretion of the physician.
u We are not able to call in prescriptions for narcotics or antibiotics. If you are in need of these
medications you must have a visit with a doctor.
u Any change of prescription will require an office visit.
u Please allow two (2) weeks advance notive for MRI and forms transfer requests
*There will be a $20.00 charge on all returned checks
We feel strongly that all patients deserve the very best medical care we can provide. Further, we feel that everyone benefits
when definitive financial arrangements are agreed upon. Accordingly, we have prepared this material to acquaint you with
our policy. Our professional services are rendered to you, not the insurance company. Therefore, payment for treatment is
your responsibility.
1.
I authorize this office to release or receive any information necessary to expedite insurance claims.
2.
I hereby authorize this office to bill my insurance company directly for their services.
3.
I authorize payment directly to this provider of my insurance benefits otherwise payable to me.
4.
In the event I receive payment from my insurance carrier, I agree to endorse any payment over to the
provider for which these fees are payable.
I,
have read the above office policies as well as the
(print name)
authorizations and my questions regarding these policies and authorizations have been answered to my satisfaction. By
signing below I accept that these policies and authorizations have been put into place for my own best interest and understand
that the staff of TLC Family Medical & Rehab Center reserves the right to enforce these policies at their discretion.
Signature of Patient (or Guardian):

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