New Patient Paperwork

In our efforts to comply with the Health Insurance Portability and Accountability Act (HIPAA), we need to be certain that we guard your privacy according to your wishes when it comes to your family, friends, and co-workers. You will be asked several questions that fall into HIPAA, please answer them to help us protect your privacy.

Telemedicine appointments: Telemedicine involves the use of audio, video, or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine visit, details of your medical history and personal health information may be discussed.

The benefits of telemedicine include having access to medical care without having to travel to the office. A potential risk is that because of specific medical conditions, or due to technical problems, a face-to-face visit still may be necessary after the telemedicine/telehealth appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to a telemedicine visit is a face-to-face visit with a provider.

All laws concerning patient access to medical records and copies of medical records apply to telemedicine. All existing confidentiality protections under federal law apply to information used or disclosed during your telemedicine visit.

You may withhold or withdraw your consent to a telemedicine visit at any time without it affecting your right to future care or treatment.

A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies: 1) how medical information about you may be used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information.

The undersigned certifies that he/she read the foregoing, was offered a copy of the Notice of Privacy Practices and is the patient, or the patient's personal representative.

You may authorize us to contact a family member or other designated person regarding your medical care or financial matters. You have the right to revoke this consent in writing except where we have already made disclosures in reliance on your prior consent.

This is to acknowledge that you authorize Symbios Medical Services to disclose your PHI to the following individual(s).

The following is an outline of financial responsibilities in relation to your care. Patients are expected to provide identification and if insured, a current copy of their insurance card(s). Patients are financially responsible for all services provided and are expected to pay at the time of service. If the patient is a minor child, the parent or accompanying adult will be financially responsible regardless of legal guardianship. Returned checks will be subject to fees.

Self-Pay: Patient is responsible for payment in full at the time of service for all services rendered.

Medicare: The office will bill Medicare for you. Patients will be responsible for the following: 1. Annual deductible. 2. Applicable copays and/or coinsurance of the allowed charges. 3. Any non-covered services. 4. Any covered service ordered by the provider which does not meet medical necessity and Medicare beneficiary has signed an Advanced Beneficiary Notice (ABN).

Commercial, PPO, and HMO Insurance Plans: All copayments, coinsurance and/or deductible or non-covered amounts are due at the time of service. Insurance is filed as a courtesy and benefits are authorized to be paid directly to Symbios. Patients are responsible for the balance if not paid by the insurance within 30 days. If a patient is unable to pay their balance, the provider will determine if it is medically necessary for the patient to be seen. If the condition allows, the patient will be rescheduled.

Out of State Insurance: If an out of state HMO/PPO insurance card is presented, the practice will verify the patient's benefits for out of state or out of network benefits. The patient may be required to pay in full for services provided, any copay, coinsurance, or deductible.

Medicaid: Patients must provide a current card at each visit. Patients are responsible for applicable copays and all non-covered services.

Worker's Compensation: Employer authorization must be provided before services are rendered or the patient will be responsible for payment in full at the time of service. If the case is dismissed or denied, the patient will be responsible for the full amount.

Personal Injury/Motor Vehicle/Other Third Party: The patient is responsible for the balance in full at the time of service. Any settlement the patient receives from your insurance company or other third party will be handled by you, your insurance company, and your attorney.

Assignment and release: I hereby assign all medical and third-party carrier benefits to be paid directly to Symbios. I agree that I will be responsible for any remaining balance. I also authorize Symbios to release any information required to process a claim to my insurance carrier and/or employer. I acknowledge that I am financially responsible for services rendered and failure to pay any outstanding balances may result in collection procedures being taken. I also agree that if my account has a credit balance, the credit will be applied to any outstanding accounts of mine, or any family member that I am a guarantor for.

Consent for treatment: I hereby authorize the providers to conduct examinations and to administer treatment as deemed medically necessary and advisable.

After hour calls: I understand that any calls made after hours to the provider on call will be subject to a telemedicine visit and will be billed as such if deemed necessary by the provider.

No shows: I understand that if I fail to come to a scheduled appointment or do not cancel at least 24 hours prior, I may be charged a "No Show" fee. Ongoing occurrences may result in dismissal from the practice.