BHARTI LALLA, MD
As it appears on insurance card
As it appears on insurance card
Please print your name in the signature field
I acknowledge that I have received and understand the notice of privacy practices for Bharti Lalla, MD containing a description of the uses and disclosures of my health information. I further understand that Bharti Lalla, MD may update its notice of privacy practices at any time and that I may receive an updated copy of Bharti Lalla, MD notice of privacy practices by submitting a request in writing for a current copy of the notice of privacy practices.
I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original.
I hereby authorize Bharti Lalla MD PA to apply for benefits on my behalf for covered services rendered by him, or by his order.I request that payment from my insurance company be made directly to Bharti Lalla MD PA (or to the party who accepts assignment).
I authorize Bharti Lalla, MD PA to charge my account all collection fees if my account is not paid in full and further collection action is necessary to collect on my account. Also, I am fully responsible for all attorney fees and court charges, if legal action is necessary.
All appointments should be cancelled 24 hours prior to the appointment. Three NO SHOW appointments will result in being discharged from the practice. I authorize cancellation fees to be charged to my account when appointments are broken.
You are solely responsible to have pre-authorization numbers for each appointment and/ or procedure prior to your appointment. Without these numbers your insurance may refuse to pay your claim and you are ultimately responsible for the total bill.
Co-payments are due at the time of service. I authorize additional charges to be added to my account if copay is not paid at the time of service.
Please print your name in the signature field
Medical Record Release
Please note: We will leave a message or send a text message confirming your appointment date and time on your answering machine.
Please note: If NO is selected no information about you will be given to any family members or friends, even in case of an emergency.
Please print your name in the signature field
PORTAL AUTHORIZATION
I authorize the release of medical information to myself at the email address above for the patient through the MD's secure email portal. Please select "I AGREE" or "I DISAGREE" in the box below.
Please print your name in the signature field
Prescription Policy
Our office policy for prescriptions requires every patient to be seen within a 3 month period for prescription refills. Prior to your visit you should prepare a list of ALL medications that need to be refilled. If you feel that your medications will run out before your next visit please advise the staff today! If you do not request your prescriptions at the time of your office visit there will be a $10.00 charge for any prescriptions refills between office visits.
Please print your name in the signature field
Acknowledgement of Privacy policy
I acknowledge that I have received and understand the notice of privacy practices for Bharti Lalla, MD containing a description of the uses and disclosures of my health information. I further understand that Bharti Lalla, MD may update its notice of privacy practices at any time and that I may receive an updated copy of Bharti Lalla, MD notice of privacy practices by submitting a request in writing for a current copy of the notice of privacy practices.
Please print your name in the signature field
Financial Policy
This is an agreement between Dr. Bharti Lalla and the Patient named on this form.The words "you", "your", and "yours", mean and refer to, the Patient. The word "account" refers to the account that has been established in the Patient's name in which charges are made and payments are applied. The words, "we", "us", and "our" refer to Dr. Bharii. Lalla. As a courtesy to you, we bill your primary insurance company on your behalf. We will estimate what your insurance company may pay, but this is not a guarantee of payment. Your insurance company will make the final determination of your eligible benefits. You acknowledge that you understand that insurance coverage for benefits is an agreement by and between you and your insurance company. Therefore, you are accepting responsibility for the charges that your insurance company does not pay.
Referral/Authorization: Your insurance company may require a referral and/or preauthorization of some medical services. Should your insurance company require a referral and/or preauthorization for services, it is your responsibility to obtain said referral and/or preauthorization. By failing to obtain the proper referral and/or preauthorization, the insurance company may reduce or deny payment for services.
Managed Care: All insurance companies require that Patient co-payments and deductibles are payable at time of service. If your are unable to pay at time of service, an additional charge of $7.00 will be assessed to the balance to cover the additional collection costs. This service fee is Patient responsibility and cannot be billed to the insurance company.
Self-Pay: If you are paying for services yourself (self-pay), then an approximated amount for the anticipated services is due at time of service. Any remaining balance will be billed to you.
Personal Injury Cases/Motor Vehicle Accidents: We do NOT submit bills for motor vehicle or personal injury claims. Patients are responsible for payment at time of service. Patients must submit bills to their insurance company. We do NOT accept letters of protection from attorneys.
Appointment Cancellation: We require a minimum of 24 hours notice for cancellation of appointments. Failure to provide the minimum notice will result in a $25 "no show fee" charged to your account.
Patient Balances: If you have a Patient balance on your account, you will be billed for the entire amount due. Your bill will show separately any previous balance, any new charges on your account, and any payments or credits applied to your account during that billing cycle. Your bill may also show pending payments from your insurance company, if applicable. The Patient balance will be clearly indicated. Unless you have made other arrangements for payment of the Patient balance approved by Dr. Bharti Lalla's billing office in writing, the amount indicated as Patient's balance is due upon receipt. Your balance will be past due if payment is not received within 30 days from the issue date printed on the statement. Dr. Bharti Lalla reserves the right to add any fees incurred for additional billing and/or collection services. For your convenience, we accept payment via personal check or credit/debit card. We accept Visa, MasterCard, American Express, and Discover. A $25 returned check fee will be charged to your account for any checks that come back as non-sufficient funds (or any other reason) by your financial institution. If necessary, Dr. Bharti Lalla may set up a regular payment schedule for you. Dr. Bharti Lalla reserves the right to report your account to credit reporting agencies if your balance goes into a past due status. Nonpayment of past due Patient balance may result in Dr. Bharti Lalla's inability to provide you with continued care. You understand that if your account is submitted to an attorney, collection agency, involved in court litigation, or reported to credit reporting agency, the fact that you received treatment/services at our office may become a matter of public record.
Transferring of medical records must be requested in writing along with a Medical Records Release form.
By signing below, you acknowledge and agree that:You understand that it is your responsibility to provide Dr. Bharti Lalla with current and accurate billing information at the time of service and you will notify Dr. Bharti Lalla immediately if there are any changes to this information. You agree to the terms and conditions contained herein. You understand that any charges not covered by your insurance company along with any co-payments and deductibles, are you responsibility.
Please print your name in the signature field
AUTHORIZATION FOR ELECTRONIC EXCHANGE OF PATIENT HEALTH INFORMATION/EPRESCRIBING
By signing this form, I authorize Bharti Lalla, MD to electronically disclose and access all protected health information (PHI) for the patient named above contained in the patients electronic medical record, including medical history, diagnosis, treatment, examination and/or information related to mental health, genetic information, birth control and family planning, substance and/or alcohol?s abuse, HIV/AIDS and sexually transmissible diseases, contained in the any Electronic Medical Records Exchange systems (Florida shots, Amazing charts, Quest/LabCorp, Surescripts used by my provider (collectively ?EMRES?).
I understand and agree that Bharti Lalla, MD and my other health care providers may place my PHI in the EMRES, and I am authorizing my PHI to be accessed ad disclosed in and through the EMRES. I understand that Bharti Lalla, MD and my other health care provider will communicate about my care through the EMRES as one method of communication and disclose my PHI in the other ways as provided to me in each of the providers Notice of Privacy Practices.
I understand that the purpose of this authorization is for use and disclosure (e.g., sharing) of PHI in the above listed patient?s electronic medical record to allow health care providers to exchange important information about treatment and to provide safe and coordinated care. This authorization gives the physician ability to ePrescribing which greatly reduces medication errors and enhances patient safety. (1) Formulary and benefit transactions ? Gives the prescriber information about which drugs are covered by the drug benefit plan. (2) Medication history transactions provide the physician with information about medications the patient is already taking to minimize the number of adverse drug events. (3) Fill status notification ? Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient's prescription has been picked up, not picked up, or partially filled.
I further understand that the electronic medical record may contain information related to health plans, insurance benefits, worker?s compensation programs, immunizations, educational programs state programs and registries as requested by The Medicare Modernization Act (MMA).
I further understand that Bharti Lalla will keep an electronic copy of my PHI in the form and format that the information exists at the time of the information is transmitted. I understand that I have a right to inspect and to obtain a copy of any PHI disclosed. I hereby release and discharge Bharti Lalla, MD, all of its successors and all persons acting under its authority from any liability that may arise from the release of PHI as I have directed. I understand that PHI shared per this authorization may no longer be protected by state or federal privacy law and could be re-disclosed by the person or entity that receives it.
This authorization will expire when I revoke my authorization or on the day that I die. I understand that I have the right to revoke this authorization at any time. If I do so in writing, I may revoke this authorization by provided a written statement to Debbie Naeger Privacy Officer at 14171 Metropolis Avenue, Fort Myers, Florida, 33904 or Fax (239) 561-3099. The revocation will be effective upon receipt, but the revocation will not apply to any PHI already released as a result of this authorization.
I understand that I refuse to sign this authorization; my refusal will not affect my enrollment in a health plan, edibility for benefits, eligibility to receive care, the quality of care that I receive. I understand that my healthcare providers may not be able to access critical heal information obtained during a prior encounter in a timely manner.
Please print your name in the signature field
