Patient Information and Service Agreement
Welcome. This form has been developed to introduce you to my practice and clarify policies, responsibilities, and billing procedures.
I am committed to my Mission: To treat injuries and pain by providing comprehensive evaluation of the musculoskeletal system and a personalized plan to promote healing, increase function and decrease pain, allowing for the full return to activity, including sport.
I welcome new patients with an initial appointment of 60 to 90 minutes. Please complete my intake form prior to your scheduled appointment so we can utilize all of our time to address your needs.
Follow up visits are typically 30 to 60 minutes.
It is your responsibility to keep the appointment time as no reminder calls will be made. Please call, email, or text me to verify the time if you have forgotten it. Your credit card will automatically be charged $50 for missed appointments or appointments canceled with less than 24 hours’ notice. This fee will not be charged if we both agree that circumstances existed that were beyond your ability to predict or control.
Billing Policy:
I am contracted with Blue Cross/Blue Shield (Anthem), Harvard Pilgrim, United Healthcare and Medicare. It is your responsibility to know and understand your benefits. I understand this might be confusing and difficult. Please contact your insurance company with any questions you may have.
I am not contracted with other insurance companies, which may not have out of network benefits. You as the guarantor are responsible for all out of network fees.
It is your responsibility to obtain a referral from your Primary Care Physician. Referrals are required by many insurance companies. They also provide me with the information I need to communicate with your PCP to ensure continuity of care. You will be responsible for the payment of the visit if you need a referral and it is not obtained prior to your visit.
Copayments are due at the time of service. This is part of the contractual agreement you have with your insurance company. If you do not know your copayment for specialists, please contact your insurance company to clarify this prior to your first appointment. Please have your copayment ready, rather than waiting for me to remind you.
Payments are accepted in the form of cash, check or credit card. Credit card payments will incur a 2.80% additional fee to cover the cost I am charged. A $35 service fee will be charged for all returned checks.
Please present any changes in your insurance at the time of your next visit.
Your insurance benefit is a contract between you and your insurance company. My billing company will do whatever they reasonably can to ensure payment of your claims. Your insurance company might ask me to send a copy of your visit notes. They might ask you to supply them with information directly. Please comply with all requests from your insurance company.
My billing company will send you a bill for uncollected copayments and charges that are your responsibility. Interest will be incurred if balance remains unpaid by 60 days. Payment plans are available upon request. If you have any questions, please contact my staff at 603-436-0220.
Please be aware that some, and perhaps all, of the services you receive may not be covered by insurance or may not be considered ‘reasonable’ or ‘necessary’. These are terms defined by each insurance company. Please contact them with any questions you might have. Services not covered by your insurance company will be your responsibility.
Certain service costs are not negotiable and may not be covered by all insurances. Per session costs include:
• Arch Supports - $60
• Exercise Teaching - $35
• Perineural Therapy - $50 to $100
• Platelet Rich Plasma - $500
• Prolotherapy - $100 to $250
• Scar treatment - $50 to $100
• Prolonged visit - $150
• Ultrasound Diagnostic Evaluation - $100 to $400
• Medical Record Fees for non-clinical situations (lawyers, disability, etc.) - $15 first 30 pages or $0.25 per page, whichever is larger
• Preparing charts & billing for lawyers- $150 (payment for anything related to a legal situation must be made in advance). No records to be released if payment has not been established.
Self-pay charges (if you do not have insurance)
• Initial Visit - $300
• Follow Up - $200
Communication:
Brief communication by email or phone is acceptable for appointment clarification, discussion of symptoms, and clarification of the plan of care. I have purchased an encrypted email – ZixMail or Hushmail - to assist with maintaining confidentiality. ZixMail will require a one-time password set up by you. Please call rather than relying on email for urgent or sensitive situations. Phone messages left at my office (603) 436-0220 will be retrieved daily during the work week. Call backs may occur after hours, so please leave non-work numbers.
True emergencies need to be addressed through the ER or by calling 911.
Acute urgencies (i.e. new injuries) will be addressed according to availability. I try to leave time in my schedule to accommodate these situations. Use my cell phone if you are calling after hours to alert me; I will rearrange my schedule to the extent that I am able. During periods that I am away, contact your PCP or other practitioners (massage, chiropractic, PT) to assist you.
I have read and understood the Patient Information & Service Agreement on the preceding two pages.
_________________________________
Name & Signature Date
HIPAA
Health Information is protected by Federal Law. The Health Insurance Portability and Accountability Act (HIPAA) is a set of evolving rules that govern how health information is protected. It is composed of the Privacy Rule and the Security Rule.
1) The Privacy Rule applies to protecting your health information in electronic, written or oral form. This includes the information that is put into your medical record, conversations your physician has with other practitioners/care givers, and billing information. The information must be protected (passwords on computers, locks on cabinets/doors). As a patient, you may ask and receive a copy of your health record. You may make corrections to your health record if it is not accurate. In this office, your information will not be shared for marketing or anything other than to communicate with your medical providers. It will, however, be sent to agencies for Workman Compensation, Disability Services, and Lawyers office, if you sign a release, at which time your information may not be as secure. If you are concerned about the way your health information is handled, please let me know in writing so I can immediately address the problem. I am obligated to assist you in a formal complaint without any retaliation. Complaint form can be found at: www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
2) The Security Rule protects your health information when it is in electronic form. The transfer of this information needs to be secure. Hushmail or ZixMail, an encrypted email, was purchased for your use and to maintain confidentiality.
Your signature indicates that you have read the HIPAA Agreement and that you agree to all the terms specified in this document.
_____________________________
Name & Signature
____________
Date
Patient’s Rights & Responsibilities
As a patient you have certain rights and responsibilities. A respectful relationship between a healthcare provider and patient is the foundation of proper medical care.
Patients have the right to:
• Receive humane care and treatment, with respect and consideration
• Privacy and confidentiality when seeking or receiving care except for life threatening conditions or situations
• Confidentiality of your health records
• Be informed of and to exercise the option to refuse to participate in any research aspect of your care without compromising access to medical care and treatment
• Receive accurate information concerning diagnosis, treatment, risks involved, and prognosis of an illness or health related condition
• Ask about reasonable alternatives to care
• A second professional opinion regarding one’s health care and treatment
• Participate actively in decisions regarding one’s health care and treatment
• Accessible information regarding the scope and availability of services
• Be informed about any legal reporting requirements regarding any aspect of screening or care
• Complain or discuss their concerns with their healthcare provider in an open forum, free from intimidation or disrespect
Patients have the responsibility to:
• Provide complete information about one’s illness/problem to enable proper evaluation and treatment
• Ask questions so that an understanding of the condition or problem is ensured
• Show respect to health personnel and other patients
• Reschedule/cancel an appointment with 24 hours advance notice so that another person may be given that time slot. $50 charge to be applied for no show appointments.
• Pay bills or file health claims in a timely manner
• Use prescription or medical devices for oneself only and as prescribed.
• Inform the practitioner(s) if one’s condition worsens or an unexpected reaction occurs from a medication
_________________________________
Name & Signature
____________
Date
Credit Card on File Authorization
I understand that convenience is not often associated with today’s healthcare environment. My Practice not only focuses on excellent healthcare service but also how to provide service as cost and time effectively as possible. I have found that collecting all known liability at the time of service is not only beneficial for the Practice, but experience has proven that my patients appreciate knowing they will not have to worry about delayed billing or payments.
I provide secured methods of accepting your payment at the time of treatment and also for keeping your credit card on file to handle any remaining balance after insurance company reimbursement.
I will work with you in establishing a payment schedule if necessary using this credit card authorization form.
I (Guarantor Name) ___________________________________
Authorize (Provider Name) Dr. Jennifer Stebbing DO
to keep my signature and credit card information on file, and to charge my account for balances that remain unpaid after two (2) billing cycles.
I understand the provider is offering this as a courtesy, and I may pay my balance in full at any time and cancel this agreement. I am authorizing the use of this card for:
Patient Name: _________________________________________________________________
Card Holder Name: _____________________________________________________________
Card Holder Address: ____________________________________________________________
Type of Credit Card: ___________________________
Credit Card Number: ___________________________________________
CVV Code (3 Digit Code on Back of Credit Card*): _______
Expiration Date: __________
Billing Zip Code: __________
Text or Email Receipt: (Provide Preference): ______________________________________
Name & Signature: ____________________________________________
Date: ____________
* American Express: 4-digit CVV code on front of card
1 Greenleaf Woods Dr., Ste. 102 Portsmouth, NH 03801 p 603 436 0220 f 603 373 8094 www.DrJenniferStebbing.com