New Patient Consent Form Web | Magnolia Endocrinology

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PATIENT CONSENT and FINANCIAL RESPONSIBILITY

Thank you for choosing us as your Endocrinology Provider. As a patient of Magnolia Endocrinology (ME) outpatient facility, I agree to the following:

RELEASE OF PRESCRIPTION HISTORY: I understand that Magnolia Endocrinology (ME) has the right to ask for any data regarding my medication history. I also understand that ME may ascertain any data regarding my medication history. This includes data that may be held by the South Carolina Prescription Monitoring Program and other sources.

PROOF OF INSURANCE. All patients must complete our patient information form before seeing the Provider. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. You need to show your proof of ID and Insurance Card at every visit as part of HIPAA and PHI regulatory policies. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

CO-PAYMENTS AND DEDUCTIBLES DUE AT TIME OF SERVICE:
- All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Please refer to your insurance policy for details. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment and any outstanding balance at each visit.
- Magnolia Endocrinology will bill most insurance companies for patients, even though they do not have to do so. If my insurance company does not pay all or part of my bill, I will pay. Full payment is due at the time of service. I may make other arrangements if I cannot pay at the time of service. I will be charged $50 for any returned checks.

CLAIMS SUBMISSION. We will submit your claims and assist you in any way we 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. 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.

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 30 days, the balance will automatically be billed to you.

NONPAYMENT. If your account is over 90 days past due, you will receive a letter stating that you have 10 days to pay your account in full. Partial payments will not be accepted. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our Providers will only be able to treat you on an emergency basis.

INSURANCE REFERRALS & PREAUTHORIZATIONS: I understand that it is my duty to fully follow all my preauthorization steps. If I elect to be treated without a referral from an approved Provider, it is my sole responsibility to pay my bill. I understand that my insurance may not pay anything if I am treated without a referral. Depending upon individual insurance carriers’ preauthorization, depending on insurance carrier, can take up to, but not limited to ten (10) business days.

NON-COVERED SERVICES. Please be aware that some, and perhaps all, of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

MULTIPLE BILLS: I understand that while I am treated at a Magnolia Endocrinology, I may receive a separate bill from other health care providers. For example, I may receive a separate bill from a laboratory, radiologist, pathologist, or other providers. I agree to pay all bills received that are not paid by my insurance company.

PATIENT/FAMILY BEHAVIOR: While at Magnolia Endocrinology’s office, I will be polite to the Staff. I will be polite to all medical providers. I will be polite, respectful, and courteous to other patients. Failure to do so may require dismissal from the practice.

MAGNOLIA ENDOCRINOLOGY IS NOT RESPONSIBLE FOR LOSS OF PERSONAL BELONGINGS: Magnolia Endocrinology is not responsible for any loss, theft, or damage to my personal belongings.

PATIENT E-MAIL: By providing my e-mail address to Magnolia Endocrinology, I permit them to use my e mail address to send me messages on health-related issues. I also permit them to use my e-mail address to send me messages on health services. In addition, I give permission to Magnolia Endocrinology to e mail me regarding clinical studies that match my medical situation. I understand I can choose not to receive such messages from Magnolia Endocrinology by contacting them.

NO SHOW FEES: I understand the importance of keeping my scheduled visits. A 24-hour advance notice is necessary for all appointment changes. A 24-hour advance notice is necessary for cancellations. Patients will be charged and billed $100.00 if they do not give a full 24-hour notice prior to cancelling or rescheduling an appointment. Our Provider’s time is especially important and if you cannot make the appointment Magnolia Endocrinology requires at least 24 hours advance notice to give your time slot to another patient who needs endocrine care. Medicaid patients will be handled according to CMS guidelines. If I keep missing my scheduled visits I may be discharged from the practice.

PHOTO RELEASES: At registration, your picture may be taken and scanned into your medical records. We may also request a photo. I.D. This is to protect your safety and prevent identity theft.

I AGREE TO THE TERMS OF THIS PATIENT CONSENT and FINANCIAL RESPONSIBILITY AGREEMENT.

Print Patient's Name*

Date of Birth*

Date & Time*

Patient or Responsible Person Signature*

Relationship to Patient*

FOR MAGNOLIA ENDOCRINOLOGY MEDICAL PRACTICE PATIENTS ONLY:

I give permission to my physician & office personnel to verbally discuss my medical condition(s) with the following person(s) below.

List Name of person(s) who you give permission to discuss your medical condition:

Print Individual Name & Phone Number*

Relationship to Patient*

Print Individual Name & Phone Number*

Relationship to Patient*

Patient Signature*

Date:*