Clemmons Urgent & Primary Care
2245-C Lewisville Clemmons Rd
Clemmons, NC27012
(336)712-8225
Assignment and Release to Clemmons Urgent & Primary:
I understand that I am financially responsible for all charges whether or not paid by my insurance company. I hereby authorized Clemmons Urgent to release all information needed to secure the payment of my benefits. I authorize the use of my signature on all insurance submissions whether manual or electronic. I further authorize Clemmons Urgent to disclose information in my medical records, including current and previous documents to other physicians and healthcare providers to whom the physician referrers me for treatment. INITIAL ______
Insurance Information / Identification:
If you have insurance you will be required to show proof of that by presenting the insurance card. Medicaid patients will be required to show their card at every visit. You will not be seen unless you present your insurance card. You will also be required to show some sort of Identification to help prevent identity theft. INITIAL ______
Minor / Child Consent:
I being the parent / guardian of the above listed patient do hereby request and authorize Clemmons Urgent to perform any necessary services for my child which are deemed advisable by the physician.
INITIAL ______
Notice of Privacy Practice:
A Notice of Privacy Practices (NPP) is provided to all patients. In it identifies: 1). How much medical information about you may be released or disclosed. 2). your rights to access medical information, amend medical information, request an accounting of disclosed information. 3). Your rights to complain if you believe your “Privacy”A NOTICE OF PRIVACY PRACTICES (NPP) IS PROVIDED TO ALL has been violated. A NPP will always be available for you to view at any time. If you would like for us to discuss your health, treatment, billing or any other private information with anyone else (example: spouse, significant other, child, etc) please inform the staff. INITIAL ______.
If you do not have insurance:
All payments are due and payable at the time services are rendered. INITIAL ______.
Co-Payment/Co-Insurance Policies:
We are obligated by law to collect your carrier designated fees at the time of each visit. We will verify your insurance benefits to the best of our ability. Please understand that this does not guarantee benefits. You, the patient, are ultimately financially responsible for the care you receive in this office. We will do our best to communicate with you in a timely manor regarding any issue with your insurance policy and will work on your behalf to resolve these issues. INITIAL ______.
Policies with a Deductible:
Deductibles can be difficult at best. If you have a deductible, it may be in your best interest to choose our self pay program rather than submit to your insurance company for payment. We are happy to provide you with a statement you can submit personally so that any charges from this office can be applied to your deductible. Please discuss this with our front desk staff to determine the best course of action.
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Policies that need prior approval:
Some insurance plans require that you obtain prior approval before being seen at our office. It is up to you to do this. Some plans will not “retro auth”visits so please make sure that you call your insurance company before being seen by our staff. If you’re insurance company denies the charges for this reason than you will be charged and responsible for the balance. INITIAL ______.
Outstanding Balances:
If there is an outstanding balance on your account, you will receive a statement from our office by mail. Please feel free to contact the billing department should you have any questions. After 60 days or on your next visit you will be required to pay it before you will be seen by the Doctor (along with any co-pay; balances, etc that are due at the time of the service). INITIAL ______.
“No Show”/Missed Appointments/Cancellations:
Our time is important; as is yours. We expect you to keep your appointments that have been scheduled by our office, however if you fail to keep your appointment AND you do not give us a 48 hour notice, you will be charged a $25.00 Fee for each missed appointment. INITIAL ______.
Release of Information:
We will release your medical information at your request and upon signing a Medical Release Form. There is a fee for processing the copy that you will personally receive. If the records are to be mailed you will also be required to pay for the postage in addition to the processing fee. If the chart is too large we will ask that you come by and pick up the records. You will be required to pay this fee immediately. You will also be required to pay the processing fee if we have to send your records to another doctor (one that we didn’t refer you to for treatment), a lawyer or any other entity (excluding your insurance company).
INITIAL ______.
Contacting you:
If we need to contact you regarding private health matters may we: Leave a message on the voicemail or answering machine? Y or N. Can we leave a message with an individual? Y or N. If Y who can we leave this information with ______what is the relationship to you? ______
• We accept cash, check, or credit card for your payments. If needed, a payment plan contract can be established through the front office.
• Any returned checks will be charged a $25.00 fee in addition to the amount of the check.
• I certify that I have read and understand the information listed above. I understand that it is my responsibility to ask questions regarding these policies if my understanding is unclear.
By signing below, you hereby acknowledge that you have received a copy of the office’s NPP, that you have read and understand all of the above statements directly pertaining to: Assignment, Release, Financial Agreement/Responsibilities, Minor/Child, NPP, No Show and release of information.
Patient Signature: ______Date: ______
Staff Witness: ______Date: ______
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