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 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

6: LAB BILLING POLICY

NOTICE OF SEPARATE BILLING - LABORATORY SERVICES

Thank you for choosing Tricity Family Medicine. During your visit, your physician may order labs for a variety of appointments such as medication checks/sick visits to confirm a diagnosis and during annual wellness/physical/preventative care to monitor and prevent disease or health problems. Some non-covered services that your provider may recommend for the best possible personalized care are Thyroid tests, Urine tests, Vitamin tests, and Hormone tests.

The purpose of this form is to help you make an informed choice about whether or not you want to receive any laboratory tests that your provider may recommend, knowing you might have to pay for them yourself. You may reschedule your lab draw appointment to contact your insurance company to determine coverage.

Although the samples are collected in this facility for your convenience, there are some tests we process in-house and others we utilize MAKO MEDICAL LABORATORIES for processing. You will receive a bill from us for our in-house services and a separate bill from MAKO MEDICAL LABORATORIES for other lab tests. Please be advised that some insurance companies mandate where your tests can be performed. The physician in this facility may be in network with your insurance company but MAKO MEDICAL LABORATORIES may not be.

Some insurance companies may also apply lab charges to your deductible/co-insurance and/or non-covered services. If you have questions as to whether your charges will be managed in this manner, please consult with your insurance company. Our office enters the insurance claim based on the entirety of the services and tests done during your visit. Tricity Family Medicine cannot guarantee coverage of your insurance claim or any specific insurance payment amounts. Please note that physicians will not change diagnosis codes to get claims paid, regardless of what your insurance carrier or MAKO MEDICAL LABORATORIES might suggest. This is considered insurance fraud and is illegal.

If you have any questions regarding your laboratory benefits, please call your insurance company, and for lab billing concerns, please contact MAKO MEDICAL LABORATORIES directly.

By signing below, I acknowledge I have read, understood, and will adhere to the Lab Billing Policies. *

I have read and understand the above information.

I acknowledge that recommended laboratory services may be necessary as part of my care and treatment.

If my insurance plan requires an additional out-of-pocket expense, I understand that it is my responsibility to pay.

Patient FULL Name *

Patient's Date of Birth *

PATIENT/GUARDIAN E-SIGNATURE *

Please print your name to confirm that you have read the form in its entirety and sign to comply with policies.

Today's Date *

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