Office Policies. E-mail data may be unsecured and result in health information being distributed to unknown third parties for which EFM is not responsible. Use of the secured patient portal is the preferred route of communication for routine matters. Phone call is the preferred route of communication for urgent matters. EFM does not provide emergency care. There may be times when Dr. Black is unavailable. If a health matter is urgent I agree to seek care at an urgent care or emergency room. The preferred urgent care for Empower Family Medicine is Urgent Care at Druid Hills 0000 X Xxxxx Xxxxx Xx XX Xxxxx X, Xxxxxxx, XX 00000. All prescription refills for chronic medications should be requested at office visits. Routine refills will not be issued by phone, fax or call. For Principal and Patients: I have reviewed the EFM Patient Agreement, Policies and Privacy Practices. I have been given ample time to ask questions regarding its content, and consent to its terms. This agreement is made voluntarily with no urgent medical care need. I understand that these authorizations take effect while Patient is enrolled with Empower Family Medicine, and that Patients or Principals have the right to revoke such authorization at any time by cancellation of the Monthly Enrollment Fee, or by written or verbal request. Patient: Principal: Medical Director: Xxxxxxx Xxxxx M.D. MEDICARE OPT OUT AGREEMENT This agreement ("Agreement") is entered into by and between Empower Family Medicine, LLC, a Georgia professional corporation, owned and operated by Dr. Xxxxxxx Xxxxx, MD, (the "Physician"), whose principal medical office is located at 000X Xxxxxxx Xxx Xxxxx 000 Xxxxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B ("Beneficiary"), who resides at .
Office Policies. Welcome to the Paradise Hyperbarics. We are pleased that you have allowed us the opportunity to try to help you or your family member recover from an indication(s) and any related symptoms. We have created this facility to provide affordable, medical-grade hyperbaric services to our patients. To help keep our services affordable, we have adopted the following policies. We appreciate your understanding and cooperation in the administration of these provisions and vow to provide you with the best Hyperbaric Oxygen Therapy (HBOT) experience possible. • All persons receiving treatment must have a prescription from a licensed physician on file prior to beginning treatments. Prescriptions or referrals for HBOT should be attached to this form. Patients can be self-referred and have an HBOT prescription written by Paradise Hyperbarics. • All clients must have a signed patient registration form and office policies on file prior to having a prescription written by Paradise Hyperbarics and before being placed on the schedule. • All parents or legal guardians, who plan to enter the chamber to accompany a child for their safety, must also have a signed patient registration form and office policies on file prior to being scheduled. Both patients must fit safely inside the chamber. Add $25 for additional mask. • All sessions must be paid in advance. To receive a package discount the entire payment for all sessions in the package must be received prior to beginning the first treatments. • While we prefer cash or check as form of payment to avoid passing 3% credit card convenience fees to patients, we do accept Visa, MasterCard, Discover, and American Express. Personal checks made payable to Paradise Hyperbarics are accepted. $30 fee for returned checks. • There is a 24-hour cancellation requirement to allow sufficient time for the facility to schedule another patient. To ensure fairness for all of our patients, all cancellations should be made at least 24-hours in advance whenever possible but must be made before 5 pm the day before your appointment. Patient is responsible to pay $109 for any same-day cancellations. • Treatments will be administered by the trained staff of the Paradise Hyperbarics. There may not be a physician on site. Any relationship with our medical director does not constitute primary care and is not a replacement for your relationship with your primary care physician. • If a block of 10 or 40 sessions are purchased and the client is unable to finish ...
Office Policies. All administrative and office staff are bound to confidentiality and cannot disclose any information. This becomes especially sensitive when relatives call the office requesting even simple information, such as an appointment time for their spouse. Even under these simplest of situations, office personnel cannot acknowledge they even know the person, nor can they disclose any information. If ongoing contact is to occur with a relative, regarding billing for example, a release of information can be signed, specifying the information you permit to be exchanged. All requests for records must be accompanied by a release of information. It is my policy to keep records for 8 years from when the record becomes inactive.
Office Policies. Xx. XxXxxxxxx is committed to providing a welcoming environment for her patients. Your time is valuable as is that of all the families served by this practice. The following policies are designed to improve everyone’s patient experience: Please arrive on time for your visit. Other patients have appointments after yours and thus families that arrive more than 10 minutes late may be asked to reschedule the visit. If you cannot make the appointment, please call more than ONE office business day ahead of time to reschedule. Last minute cancellations and no-shows may be charged a fee. Reminder calls are made as a courtesy only. It is your responsibility to know the time and date of your appointment. Tests (labs and X rays) may be requested prior to the appointment. Please ensure you have the test done on time so the results can be reviewed with you at your upcoming appointment. The due date is indicated on your visit summary and test order sheet. You may be asked to reschedule if the results are not available in time or if the tests have not been obtained. Patients who miss more than 3 appointments may be asked to continue their care with another practice. Please have your medication list ready for review during office visits. Please contact your pharmacy for all prescription refill requests. Please allow at least 2-3 business days for processing. Prescription refills require regular office visits. To ensure you or your child’s safety, a regular evaluation of the condition and medication interactions is required. If you are transferring care from another provider or center, please ensure that all previous clinic notes have been sent BEFORE the scheduled appointment.
Office Policies. It is usual and customary for the fee to be paid at the beginning of each counseling session. Other arrangements will have to be made in advance. Sessions start on the hour and are usually held once a week at first to ensure the greatest change possible. All requests for copies of your file or amendments are to be made in writing.
Office Policies. It is usual and customary for the fee to be paid at the beginning of each counseling session. Other arrangements will have to be made in advance. Sessions are usually held once a week at first to ensure the greatest change possible. There is a $25 NSF for all checks returned. All requests for copies of your file or amendments are to be made in writing.
Office Policies. Welcome to Inland Empire Dental Group! We are excited to have you as our lifelong patient! It is our goal to provide you with the highest quality dentistry and care possible in a courteous and efficient manner. In order to achieve this goal, we ask that you read and agree to the following office policies:
Office Policies. Welcome to All Care Dental! We are excited to have you as our lifelong patient! It is our goal to provide you with the highest quality dentistry and care possible in a courteous and efficient manner. In order to achieve this goal, we ask that you read and agree to the following office policies:
Office Policies. Phone Access and Emergencies: I am usually available by phone 24 hours a day, and will check my voice mail several times a day, Monday through Thursday, 9 AM to 5 PM. I do not answer the phone when I am in session with another client. You may leave a message at any time, but I will not receive messages left after 6 PM until the next morning. However, if you truly have an emergency or need to reach me urgently, please call the answering service at any hour. The phone number is (000) 000-0000 and is included in my voice mail message. In case of an emergency on a weekend, the answering service will connect you with myself or the psychologist on-call. If I am out of town, the psychologist on-call will be covering for me and can be reached through the answering service. Should you need extensive phone contact or an office visit, my on-call colleague will xxxx you at his or her own standing rate. If you are unable to reach me or the psychologist on-call, please call the Multnomah County Health Crisis Line (000) 000-0000 in Portland or go to the nearest hospital emergency room. Billing: Fees are $240 for an initial intake/consultation session, $150 for a standard individual psychotherapy session and $175 for a couples therapy session. Sessions ordinarily last 50 minutes although for the initial intake session we will usually meet for an hour. The fee for the first consultation interview/session is due in full at the time of that session. Unless we have agreed on another arrangement, you will be responsible for paying your xxxx in full at the time of each session. If insurance is paying a portion of this fee directly, you must still cover the deductible, if any, and provide the co-payment at the time of each session. I would appreciate your bringing to the session a check already made out so that we may use our entire time on your concerns. I use a billing service. If you have any questions regarding your xxxx, please call my bookkeeper at (000) 000-0000. If you are using insurance, please be aware that your insurance coverage constitutes a financial contract between you and your company, and that you are responsible for any balance not paid by your insurance company. Fees may also be charged on a pro-rated basis for other professional activities necessary for good clinical care or for professional services you may need or request of me. These include: time spent in letter and report writing or treatment summaries on your behalf, telephone consultation time initia...
Office Policies. The appointment times are reserved exclusively for you. Please consider your appointment card as your confirmation. We understand that conflicts in schedules sometimes arise. If that is the case, we ask that you give us a 48 business hour notice so we can use that valuable time for patients who may be in need. We hope that you will help us in this issue so we can better serve you and our other patients. A
