New Form Test

Consent to Acquire Medication History

I give consent for Medical Vein Clinic to electronically obtain my medication history. Medical Vein Clinic will use this information for reference and to make sure any medications prescribed will not interact with medications I may be taking.

Financial Responsibility

Self-pay and previous balance amounts are due and payable at the time of service. Insurance co-payments are mandated by your insurance company and MUST be paid at each visit. Patients with insurance claims pending will be sent statements for the full amount due until the account is satisfied. I agree that if the insurance company denies benefits for any reason, I am responsible for the full amount owed for services provided.

I request that payment of authorized insurance and Medicare benefits be made payable to Medical Vein Clinic on my behalf for services furnished to me. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. In the event that my account is turned over to a collection agency, I agree to pay all reasonable costs of collection and understand that I may no longer be a patient at this office. I understand and agree to pay a returned charge of $25 for each check that is returned for any reason.

I authorize the holder of my medical information to release any and all information to Medical Vein Clinic, its agents, my insurance carrier(s), or other entities, as needed to determine my benefits or the benefits for my dependents. If I have health insurance coverage under an HMO, I authorize the practice to release information concerning my diagnosis and treatment to my primary care or referring physician after each visit.

I have been made aware of the privacy policies of the practice and have received, reviewed, or been given the option to receive and review, a copy of the Notice of Privacy Practice.

HIPPA Consent

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize Medical Vein Clinic to use and disclose my protected health information (PHI) to carry out the following:

• Treatment (including direct and indirect treatment by other healthcare providers involved in my treatment)
• Obtain payment from third party payers (e.g. my insurance company)
• The day-to-day healthcare operations of Medical Vein Clinic
• I have also been informed of, and given, the right to review a secure copy of the Medical Vein Clinic Privacy Statement, which contains a more complete description of the uses and disclosure of my PHI and my rights under HIPAA. I understand that Medical Vein Clinic reserves the right to change the terms of this notice at any time and that I may contact Medical Vein Clinic at any time to obtain the most current copy of this notice.

I understand that I may revoke this consent at any time though proper notification. However, any use or disclosure that occurred prior to revocation date is not affected.

Thank you for choosing Medical Vein Clinic as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of your visit, the financial responsibility for payment is yours.

If you have had any changes in your insurance coverage – even if there is only a small change in the copayment amount or a change in the expiration date of the policy – you must notify us. Even a small discrepancy on the form can lead to a claim denial.

We emphasize that as a medical care provider, our relationship is with you and not with your insurance company. It is your responsibility to know your policy. Again, we thank you for choosing Medical Vein Clinic as your healthcare provider and are here to help you!

We will bill your insurance as applicable, however, you are ultimately responsible for any fees and costs not covered or paid by your insurance. Questions about non-payment should be directed to your insurance company.

If you are unable to keep your scheduled appointment, we ask that you give adequate notice; so that we may open your reserved time for another patient. This helps us stay efficient in our office, but most importantly helps our patients on our “waiting list” and to our staff as well.

Short Notice or “No Show” Cancellations will be charged the following fees:

• $25.00 for Consults / 24 hour notice required
• $50.00 for Ultrasound Studies / 3 days notice required
• $50.00 for Sclerotherapy / 3 days notice required
• $100.00 for Procedures / 3 days notice required

Please know, each appointment canceled that falls within this timeframe, can be reviewed and waived by management, due to extenuating circumstances not within your control. If the appointment is missed without proper notice of cancellation, the fee becomes non-refundable.

This is an agreement to accept our services. We will attempt to collect unpaid balances for a period of 30 days and upon no agreement reached, the unpaid debt for our services will be transferred to our collection agency, The Phoenix Recovery Group, and will be subjected to additional fees and expenses for that process. In the case your account is forwarded to the collection agency, you may no longer be a patient at this office.

Individual’s Financial Responsibility

I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.

I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

Co-payments, co-insurance, and/or deductibles are due at the time of service.

If my plan requires a referral, Medical Vein Clinic will do our best to obtain with the first request; but ultimately may need your assistance with follow-up.

In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided (Medicare exclusions apply).

If I am uninsured, I agree to pay for the medical services rendered to me at the time of service.

Insurance Authorization for Assignment of Benefits

I hereby authorize and direct payment of my medical benefits to Medical Vein Clinic on my behalf for any services furnished to me by the providers.

Authorization to Release Records

I hereby authorize Medical Vein Clinic to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

Medicare Request for Payment

I request payment of authorized Medicare benefits to me or on my behalf for any services furnished to me by or in Medical Vein Clinic. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.

Payment Plan Arrangements

I understand that payment plan arrangements can be made, and all arrangements made will require me to keep a credit card on file with my signed consent authorizing automatic monthly payment deductions. In the event that a payment is declined, a $30 non-refundable late fee will be applied and one attempt will be allotted to make the late payment out of good faith. Any additional declined payments thereafter will result in termination of payment plan arrangements and the remaining balance will be forwarded to a collection agency.

I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THE PATIENT FINANCIAL RESPONSIBILITY FORM.