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(Please give your insurance card to the receptionist.)
I, the undersigned authorize payment of medical benefits to Northstar Surgery Specialists, P.A. for any services furnished me by the physician. I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided by me. This information will be used for the purpose of evaluating and administering claims of benefits.
1. In case of an Emergency, Please Notify :
2.Can Confitenial Messages be left on you:
I have reviewed the Notice of Privacy Practices of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice’s legal duties with respect to my PHI. I understand that I am entitled to receive a copy of this information upon request. I also acknowledge the following cancellation/no show policy: New patients that no show to a scheduled appointment are subject to a $50 no show charge. Established/post-operative patients are subject to a cancellation/reschedule/no show charge of $50 if a 24 hour notice is not given, 7 day notice must be given to cancel/reschedule surgery, if 7 day notice is not given, you are subject to a $250 cancellation fee.
I am requesting that the medical information be transferred to Vineet Choudhry MD. I understand that the information in my or my child’s health record may include information relating to STD, AIDS, or HIV. It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
Chief Complaint/Purpose of Visit:
Please List all the Current and Past Medical Conditions
Please list any pertinent descriptions, if needed, of any above conditions checked:
Surgical History - Please list Previous Operations and the year when they were performed: None
Medications- Please list all medications you are taking: None
Allergies- Please list any allergies to medications below: None Latex
Social History W S Sep
Does anyone in your family have any of the following?
Are you currently being treated by a physician for any of the following? Please check the box if “Yes.”
Please explain any “Yes” answers below:
Please complete this form in its entirety. This form serves as confirmation that you are aware that Northstar Surgery Specialists P.A. has a policy that requires each patient to follow a payment plan with a credit card on file. I,hereby consent to follow the payment agreement given below with strict abidance. Should I have any difficulty, I fully accept it as my responsibility to report this matter to Northstar Surgery Specialists before my next payment, so as to allow for alternate arrangements to be made. This policy is in effect due to the raise in patient deductibles and patient responsibility due to the change in health insurance policies and guidelines. If you have any questions about your coverage, please contact your insurance company on the number listed on the back of your insurance card. If surgery is required, a cost estimation will be provided to you prior to surgery upon request The benefit of this form is that no cost will be collected up front prior to surgery. By signing below, this allows us to set you up on a payment plan of $100/month for any and all charges incurred from office visits and operations. If you decline to put your card on file, you will be responsible for paying your amount due in full PRIOR TO SERVICES, unless alternate payment arrangements have been agreed upon by the billing administrator of NorthStar Surgery Specialists,P.A.
The below credit card will be used for any charge incurred from office visits/operations. This card will be set up for a payment plan of $100/month after insurance’s final determination unless otherwise specified (defaults to the 1st day of every month unless otherwise specified)
I decline to put my card on file, with the understanding that will be responsible for payment in FULL of any balance prior to any procedure performed/office visit.