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

3: FEES, PAYMENT & BILLING POLICIES

FEES, PAYMENT & BILLING POLICIES

Your medical insurance policy is a contract between you and the insurance carrier. Your coverage, the requirements for pre-authorization, deductibles, co-payments and co-insurance are all defined in your policy and their verification is your responsibility.

You are responsible for all charges from the date of service. As a courtesy, we will file all claims for our service with your insurance company. Make sure that all the information you provided is accurate and up-to-date. If we have not received payment from your insurance company within 60 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid whether by you or by your insurance company.

We require all patients to sign a copy of our Patient Registration/Demographic Form that assigns insurance benefits to be paid directly to Tricity Family Medicine & Urgent Care Clinic, PLLC. In the event your insurance company sends payment directly to you, it is your responsibility to sign the check over to Tricity Family Medicine & Urgent Care Clinic, PLLC.

We cannot waive any co-payments, deductibles or coinsurance amounts defined as patient responsibility under the terms of our contract with these various plans. If your insurance plan requires a co-payment, such co-payment is due at the time of service; otherwise, your appointment may have to be cancelled and rescheduled. For your convenience, we accept Cash, Visa, MasterCard, Discover, or Care Credit.

RETURNED CHECKS - There is a fee (currently $25) for any checks returned by the bank.

AFTER HOURS/WEEKEND /HOLIDAY CHARGES: There will be patient responsibility of $35 for after-hours if not covered by insurance. An after-hours fee is applicable for any visit outside Monday - Friday 8:00 a.m.- 5:00 p.m. when we are open or on a holiday or weekend.

MISSED APPOINTMENT FEE - Our office requests that if an appointment needs to be canceled, we receive notice no later than 24 hours prior to the appointment. We charge $35.00 for a no-show appointment, to be collected on or before your next appointment. Three or more reschedules/ cancellations will require a credit card on file and a $50.00 deposit prior to scheduling future appointments.

DELINQUENT ACCOUNTS: Any outstanding balance that is 60 days overdue, a $15 Service Charge will be imposed to help cover the costs involved in continuously sending overdue bills. For any outstanding balance that is 90 days overdue, your account may be forwarded to a collections agency and be subject to a collection fee. Your new balance with collection fee will be doubled of your unpaid balance.

BY CHECKING THE BOX, YOU AGREE TO ABOVE FEES, PAYMENT & BILLING POLICIES OF TRICITY FAMILY MEDICINE & URGENT CARE CLINIC, PLLC.

*Required Field

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Responsible Party (if patient is minor)

Relationship to Patient

Father

Mother

Grandfather

Grandmother

Guardian

E-SIGNATURE *

PRINT NAME (Guarantor/ Responsible Party)

Signature Date *

* Required field