NEW PATIENT FORM
We take all commercial, Medicare, and Medicaid Plans.
Before your first visit, please print and fill out these forms. For your appointment, be sure to bring with you:
- Photo ID
- Insurance card
- Filled out New Patient forms
Allowed Amount
Also referred to as approved charge, allowable charge, this is the dollar amount typically considered payment in full by your insurance company along with its network providers. The allowed amount is a discounted rate rather than the actual charge. For example, you visit a doctor who is an in-network provider of your insurance, and the total charge for the visit was $100. Your doctor is required to accept $80 as payment in full for the visit. This is the allowed amount. Your insurance will pay your doctor $80, minus any co-pay or deductible that you may owe. The remaining $20 is considered “write off”, and you cannot be billed for it. If your doctor is not within your insurance network (an out of network provider) you may be responsible for the full charge of $100.
Co-Payment (Copay):
A dollar amount your insurance may require you to pay for an office visit at the time of your appointment. It is required to be paid at every office visit.
Coinsurance
The amount that your insurance may require you to pay for covered medical services
After you have satisfied co-payment and/or deductible. It is typically expressed as a percentage (%) of the allowable charge for covered medical services. For example: if the coinsurance is 80/20 your insurance covers 80% of the allowable charge, then you are required to pay the remaining 20% of coinsurance.
Deductible:
A dollar amount that your insurance may require you to pay out of pocket each year
BEFORE your insurance plan begins to make payments for claims. Not all plans require a deductible; therefor always check with your insurance company to see if your plan has any deductibles. Deductibles reset on a renewal date, which is typically January 1st
Out-of-network Providers:
Healthcare providers who are not contracted with the health insurance plan. Typically, if you visit a provider within your insurance’s network (in-network provider), the dollar amount for the medical services will be less than if you go to an out-of-network provider.
Out-of-Pocket Limit (OOP Limit, Stop-Loss or Coinsurance Limit):
The most you have to pay for covered medical services in a plan year. After you spend this amount on a deductible, co-pay, and coinsurance than will your insurance pay 100% of the costs of covered benefits. Just like the deductibles, out-of-pocket maximum resets with the plan every year.
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your health records:
- You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records:
- You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address
- We will consider all reasonable requests and must say “yes” if you tell us, you would be in danger if we do not.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations
- We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of times we’ve shared your health information for six years prior to the day you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, costbased fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your right by contacting us using the information on the back page.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting HHS Privacy Complaints
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in payment for your care
- Share information in a disaster relief situation-- If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: HHS Privacy Complaints
Our Uses and Disclosures:
How do we typically use or share your health information? We typically use or share your health information in the following ways.
Help manage the health care treatment you receive:
- We can use your health information and share it with professionals who are treating you Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services
Run our organization:
- We can use and disclose your information to run our organization and contact when necessary. Example: We use health information about you to develop better services for you
- We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Pay for your health services:
- We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan:
- We may disclose your health information to your health plan sponsor for plan administration Example: Your Company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director:
- We can share health information about you with organ procurement organizations.
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests:
- We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security and presidential protective services
Respond to lawsuits and legal actions:
- We can share health information about you in response to a court or administrative order, or in response to a subpoena
Changes to the Terms of This Notice
- We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be able available upon request, on our website, and we will mail a copy to you.