Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

4: CREDIT CARD ON FILE POLICY

CREDIT CARD ON FILE POLICY

Thank you for choosing Tricity Family Medicine & Urgent Care Clinic, PLLC for your health needs. We are committed to providing you with exceptional care, as well as making our insurance billing processes as simple and efficient as possible. With the changing environment in healthcare, more responsibility of payment is being placed on the patient in the form of copays and deductibles. Thus, it has become necessary to ensure we have a guarantee of payment on file in our office.

Effective Monday, October 17th, 2022, Tricity Family Medicine will require all patients keep an active credit card on file with us. We will bill your insurance company first and upon their determination of benefits, we will only charge/refund your credit card when they inform us of patient responsibility different from patient payment at the time of service. Circumstances when your card would be charged/or refunded include but are not limited to: (1) Missed or canceled appointments without 24-hour notice (2) Missed co-payments, deductible and co-insurance (3) Any non-covered services and/or denial of services allocated to patient responsibility (4) Any services unpaid due to missing or incorrect information provided to our office for billing (5) Any amount not paid by your insurance 60 days after a corrected claim has been file (6) Refund due to patient upon all visits paid from insurance and patient account in good standing.

This, in no way will compromise your ability to dispute a charge or question your insurance company?s determination of payment.

We will continue to verify patient responsibility prior to each visit and collect your patient responsibility in person to avoid any later charges on your card. If you have any questions about this payment method, do not hesitate to ask.

Your credit card information is not kept on file in our offices. It is kept securely offsite by our Payment Gateway Helcim and our offices do not have access to the full credit card number once payment is processed.

By signing below, I acknowledge I have read, understood and agree to adhere to Credit Card on File Policy.

I acknowledge & understand: (select 1 option) *

ACCEPT - I, the undersigned, authorize and request Tricity Family Medicine to charge or refund my credit/debit card on file for balances due for services rendered that my insurance company identifies as my financial responsibility as shown on my Explanation of Benefits (EOB). I understand I must keep this card information current in this office. Cards denying could incur additional fees.

DECLINE - I decline to keep my card on file. I take responsibility for paying upon insurance claim processing by my health insurance plan. I understand that any balance over 30 days past due will incur an additional $5.00 charge for 2nd and 3rd statements for continued collection efforts. After 3 statements, the account will transfer to the collection agency with an additional 50% collection fee, and no appointments until the account is cleared.

Select 1 option.

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Parent/Guardian or Responsible Party Name

Relationship to Patient

Mother

Father

Grandmother

Grandfather

Other

Signature Date *

* Required field