PERSONAL INFORMATION
Census bureau categorization. Please choose one.
please choose one
please enter your email address
INSURANCE INFORMATION
*Please be advised that HealthWise Internal Medicine does not accept Medicaid.
EMPLOYMENT INFORMATION
Please select your employment status.
Please enter your employer's name.
HEALTH HABITS
FAMILY HISTORY
CONDITIONS
CURRENT SYMPTOMS
MALE PATIENTS
FEMALE PATIENTS
MEDICATIONS
PHARMACY INFORMATION
LAB AND X-RAY AGREEMENT
I understand that laboratory studies and/or x-rays deemed necessary for evaluation and treatment of my illness and/or for maintenance of my health status may be ordered and given to me.
I understand that if I do not hear from the office within five (5) business days for x-ray results or two (2) weeks for lab results, I will call the office.
FINANCIAL AGREEMENT
Thank you for choosing HealthWise Internal Medicine as your healthcare provider. We are committed to building a successful doctor-patient relationship with you and your family. Your clear understanding of our patient financial responsibility policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc.).
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in. We accept cash, check, money orders or credit cards. Absolutely no post-dated checks will be accepted.
Insurance is a contract between you and your insurance company. In most cases, we are NOT a party of this contract. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
Self-pay accounts are patients without insurance coverage or patients without an insurance card on file with us. It is always the responsibility of the patient to know if our office is participating with their plan. If there is a discrepancy with information provided to us by the patient, the patient will be considered self-pay until the correct information is provided. Self-pay patients will be required to make payment at time of service.
If you need to cancel an appointment, we ask for at least a 24-hour notice. This allows us to offer the appointment to another patient. If you fail to keep your appointments without letting us know in advance, you may be charged a $25.00 missed appointment fee.
The charge for a returned check is $25.00 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.
Payment in full is expected on receipt of your billing statement. The statement will reflect the amount you owe after your insurance, if any, has processed your claim. If you are unable to make the payment in full, please call us so that a payment arrangement can be made to bring your account current. Please note that payment arrangements will be issued at our discretion.
