Grosso Family Medicine, PC
Office Policies and Other Information
Thank you for choosing Grosso Family Medicine as your primary care provider. We are committed to providing you with quality and affordable healthcare. Please review the listed office policies and procedures, ask us any questions you may have, and then complete, sign, and date where indicated. We ask that you print Page 3 of this document and bring it with you to your appointment so we may scan it into your Electronic Medical Record. Please keep a copy for your records.
Release of Medical Information and Authorization to Pay Insurance Benefits
I authorize my physician to release information from my medical record to my insurance carrier(s), or government agency for the processing of claims for medical benefits. I request that my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to my physician, on my behalf.
Co-Payments and Deductibles
Insurance co-pays and deductibles are due at the time of service. Please understand that insurance companies require that we collect co-payments and deductibles at the time of service, failure on our part to do so could be considered fraud. We accept cash, checks, and credit cards for payment. Checks should be made out to ‘Grosso Family Medicine’. Outstanding balances may be paid at the office, by mail, or to Complete Billing Systems, Inc., Delmont, PA. We ask that all accounts be kept current.
Non-Covered Services
Please be aware that someof the services you receive may be uncovered or not considered reasonable or necessary by your insurance company. You will be responsible for paying for any of these uncovered services. Should lab or other testing outside the office be required, those entities will bill your insurance carrier. Once again, be aware that some of these services may be non-covered or not considered reasonable or necessary by your insurance company.
Proof of Insurance
All patients must complete our patient information form before seeing the doctor. We obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim.
Coverage Changes
If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
Non-Payment
In general, payments for office visits have 3 parts: co-pay, coverage paid by insurance, and any balance remaining. If you have a balance remaining after your visit, you will be mailed a bill. It is your responsibility to pay this remaining balance.
Claims Submission
We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Our insurance billing is handled very professionally by Complete Billing Systems, Inc. located in Delmont, PA. They handle all of our insurance processing and submissions. We will do our best to help you obtain payment for your office visit, but please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
Cash Payments
Grosso Family Medicine does provide services to individuals without insurance. This service is provided on a fee-for-service basis. Payment is due at the time of service. Unfortunately, we cannot bill patients for services provided on a “cash only” basis. We would be happy to discuss our fee schedule with you upon request.
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Workers Compensation/Disability/Auto Related
Grosso Family Medicine does not perform disability exams. We do accept Workers Compensation. Auto accident related visits must be paid in full at the time of service; the patient will be provided the appropriate documentation for reimbursement from auto insurance.
Dismissal
If for any reason you were to be dismissed from the care of Grosso Family Medicine, you will be notified by certified mail that you have 30 days to find alternative medical care. During that 30 day period, Dr.Grosso will only be able to treat you on an emergency basis.
Completion of Forms
We ask that all paper forms for Dr.Grosso to complete be submitted during the scheduled visit(school physicals, immunization forms, driver’s license physicals, etc.). A visit is required if the patient has not been seen in the office for more than 3 months. CDL physicals are performed in the office and always require an office visit. Forms submitted outside of an office visit should be given three business days for completion. There will be a $10 service fee to process all forms submitted outside of an office visit.
Missed Appointments
Unless cancelled at least 24 hours in advance, our policy is to charge $25 for missed appointments. If you fail to keep your appointment, you are taking an appointment spot that could have been used by someone else.
Returned Checks
For any check that is returned, due to non-sufficient funds, you will be charged a $25 returned check fee.
If you use the secure email via the practices Patient Portal, your communication with our staff will be confidential. However, all internet usage does have some inherent risk of “hacking” no matter how secure the system; the encryption in our system is placed there to help prevent this. Grosso Family Medicine does not control the security of any email system whether encrypted or otherwise. You acknowledge that communicating personal health information via email is at your own risk.
Phone Calls
Every phone call is important to us and we will attempt to answer your calls and return your phone messages as promptly as possible. All staff may be occupied providing patient care when you call. If this occurs, please leave a message and a phone number where you know we will be able to reach you. All messages are reviewed by Dr.Grosso; however, your call may be returned by his nurse/office manager. Our staff will not leave their scheduled patients to return phone calls; these are generally answered in between scheduled patients or after patient care sessions are finished.
Referrals
Certain referrals for specialist evaluation or diagnostic testing may require insurance pre-authorization and cannot be processed immediately. Insurance guidelines prohibit us from backdating referrals. We require three business days for the processing of routine referrals.
When requesting a referral, please include the following information: the name of the doctor or test requested, the date of the appointment or test for which you need the referral (if already scheduled), your insurance information, and if you prefer to have mailed to you or you will pick up.
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Telephone Release and Signature Page
Telephone Release
I give consent and authorization for the staff of Grosso Family Medicine, or billing staff of Complete Billing Systems, Inc, to leave protected Health Care Information about me or for me on my answering machine or voice mail via the telephone number I have listed below. I understand I may revoke this privilege at any time by submitting my request in writing to this office.
______
(Phone Number)
Alternative Contact
Is there anyone else, other than you, that you authorize Grosso Family Medicine to release or discuss your Protected Health Information with?
______
(Name)
______
(Relationship)
______
(Signature) (Date)
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. If you have any questions about our office policies and/or procedures please ask us and we will be happy to answer any questions you may have.
I have read and understand the office policies and agree to abide by its guidelines. I also acknowledge that I have read and understand the Notice of Privacy Practices and a copy of this policy is available to me upon my request.
______
(Signature of patient or responsible party) (Date)
*If patient did not sign, give reason and initial______
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