Patient Demographic Sheet (Page 2 of 2) in pdf

Patient Name:

Today’s Date:

FINANCIAL POLICY

We are committed to providing you with quality and affordable health care. Your clear understanding of our Financial Policy is

important to our professional relationship. Our front desk receptionist and billing staff will be happy to assist in answering any

further questions you may have. A copy will be provided to you upon request

Insurance. We participate with Medicare, Blue Cross Blue Shield and several commercial insurance companies. You must provide

our office with the necessary billing information for the visit, we will submit the charge on your behalf to your insurance. You will be

asked to provide us with your insurance card(s) at each visit. Payment of all non-covered services and supplies will be requested at

your service visit. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by

a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify

your coverage. Knowing your insurance benefits is your responsibility.

Guarantee of Payment. All copays must be paid at the time of service. I hereby guarantee payment of all charges not paid by

insurance, together with all necessary collection expenses. I understand that all bills are payable and become due upon

presentation.

Nonpayment. A statement fee of $3.00 will be charged for all billing statements issued on accounts with balances over 60 days past

due. If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full.

Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer

your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to

occur, you will be notified by certified mail that you have 30 days to find alternative medical care. During that 30-day period, our

physicians will only be able to treat you on an emergency basis.

Returned Check. A $35 charge will be applied to all returned checks.

Missed appointments. Appointments that are not canceled at least one hour prior to the appointment will be considered a no show.

Our office does not charge for missed appointments, however three no show appointments in a 12 month period could result in

discharge from the practice. Please help us to serve you better by keeping your regularly scheduled appointment.

INSURANCE PATIENTS I hereby authorize Family Practice of Cadillac, P.C. and its employees to release any/all medical information

necessary to process claim(s) to my insurance carrier(s). I irrevocably authorize the insurance carrier(s) to assign all

benefits/payments directly to Family Practice of Cadillac, P.C. I understand that I am financially responsible for all charges whether

or not my insurance covers those charges.

MEDICARE PATIENTS: I certify that the information given by me in applying for payment under Title XVII of the Social Security Act

is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or

the Medicare Program or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that

payment of authorized benefits be made on my behalf directly to the provider. I further hereby authorize Medicare or their

contracted carrier to furnish to the above named providers of service any information regarding my Medicare claims under Title XVII

of the Social Security Act.

By signing below, I acknowledge that I have read and agreed to this Financial Policy.

______________________________________________________________________

_________________________

Patient or Personal Representative Signature

Date

RECORDS RELEASE

Notice of Privacy Practices. The Notice of Privacy Practices explains how Family Practice of Cadillac, P.C. may use and disclose your

health information. By signing below, I acknowledge receipt of the Notice of Privacy Practices of Family Practice of Cadillac, P.C.

Prescription History Consent. By signing below, I give Family Practice of Cadillac, P.C. permission to access a two year history of my

medications for my care and treatment.

______________________________________________________________________

_________________________

Patient or Personal Representative Signature

Date

______________________________________________________________________

__________________________

Name of Personal Representative

Relationship

08/01/2012

Patient Demographic Sheet Page 2

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