New Patient Paperwork

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Insurance Information
Primary Insurance

Secondary Insurance

Copayments are due at the time of service. There is a $5 billing fee for all copayments not clilected at the time of service. Whether are not your insurance pay in full, a portion, or nothing at all for services rendered, is a matter between you and your insurance carrier. Any unpaid balance is due within 30 days of treatment date, unless other arrangement have been made. Finance charges at the rate of 1.5% per month will be assessed for all patients balances not paid within 30 days. ALL THE LABORATORY TEST DONE IN THE OFFICE IS THE PATIENT’S RESPONSIBILITY. Payment is accepted in the front of cash, check, money order, Visa or MasterCard.

There is a $25 charge for all returned checks. There is a $25 charge for all missed appointments cancelled less than 24 hours in advance. If you need to cancel an appointment, you must call the office at least 24 hours in advance.cel an appointment, you must call the office at least 24 hours in advance.

If you are more than 15minutes late for your scheduled appointment we cannot guarantee you will be seen at that time and you will be charged $25 for the missed appointment.


, hereby authorize Prime Pediatrics, LLC to apply for benefits on minor’s behalf for covered services rendered. I request payment to be made directly to Prime Pediatrics, LLC. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or, any related claim to the above named billing agent. I permit copy of this authorization to be used in place of the original. Either the above-named carrier or I may revoke this authorization at any time in writing. I agree to be legally responsible for any and all charges incurred for the patient name above.


Prime Pediatrics, LLC.
Notice Of Privacy Practices

We are required by law to protect the privacy of your protected health Information (PHI). This document describes how medical Information about you may be used and disclosed. It also explains how you can gain access to your medical information and who to contact should you have any complaint. Please read this document carefully and sign the bottom of the form to acknowledge that you have received It.
Uses and Disclosures of Protected Health Information:
Your protected health Information may be used and disclosed by our physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
Treatment: Your PHI may be shared with employees and contractors of the provider, or with other health care providers who are treating you or consulting in your care.
Payment: Your PHI may be shared with your insurer or other third-party payer who is responsible for paying all or part of the cost for your care.
Health Operations: We may use and disclose information that is necessary for our operation, such as internal quality assessments, contacting other health care providers about treatment alternatives, licensing, employee review activities, etc. We may use sign in sheet at the registration desk and we may call you by name in the waiting room when the physician is ready to see you.
We may use or disclose your PHI In the following situations without your authorization, including: public health issues as required by law, communicable disease, health oversight, abuse or neglect, FDA requirement, legal proceedings, law enforcement, coroners, funeral directors, organ donations, research, criminal activity, military activity, national security, and worker's compensation. We are required by law to make disclosures to you and when required by the Secretary of the Department of Health and Human Services to Investigate or determine our compliance with the requirements of Section 164.500.
You may be asked to sign a specific authorization for release of medical records, which will authorize us to make spacing disclosures that are not covered under the above sections. You may revoke any consent or authorization provided to us by giving a written notice of evocation.
Your Rights:

  1. You have the right to Inspect and copy your health information.
  2. If you feel that the health Information we have about you is incomplete or inaccurate, you have the right to request an amendment to your medical records. The request must be made in writing with the reason for the request if we do not agree with your request, you have the right to ask that your statement be place din the medical record.
  3. You have the right to find out how your health Information Is used and to whom it is disclosed. You may request an accounting of your medical record disclosures made by us, except for the disclosures made for treatment, payment and health care operations.
  4. You have the right to request a restriction of your protected health Information. This means you may ask us not to use or disclose any part of you r PHI for the purposes of treatment. payment or healthcare operations. You may also request that any part of your PHI not be disclosed to a specific person, or for notification purpose as described in this Notice of Privacy Practices. Your request must be in writing and must states the specific restriction requested and to who you want the restriction to apply. Your physician is not obligated to agree to a restriction that you may request if the physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Professional.
  5. You have the right to receive a paper copy of this notice.

We reserve the right to change the terms of this notice and will inform you by mail of any changes.
Complaints:
You may complain to us or to the Secretary of Health and Human Services If you believe we have violated your privacy rights. You may file a complaint with us by notifying our HI PAA Compliance Officer in person, by phone or in writing at the office address. We will not retaliate against you for filing a complaint.
Please acknowledge that you have reviewed this notice of Privacy Practices by signing below.


No Show / Late Cancellation Policy

This policy has been established to help us serve you better.

It is necessary for us to make appointments in order to see our patients as efficiently as possible. No – Shows and late – cancellations cause problems that go beyond financial impacted on our practice. When an appointment is made, it takes an available time slot away from another patient. No – Show and late- cancellations delay the delivery of health care to other patients, some who are quite ill.

A “no show” is missing a scheduled appointment. A “late cancellation” is canceling an appointment without calling us to cancel 24 hours in advance of an office visit or 48 hours in advance of produce.

We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis.

A charge of $25 will be assessed for each no show or late cancellation of visit appointment if less than 24 hour notice is given.

Please understand that insurance companies consider this charge to be entirely the patient’s responsibility.