Insurance Intake

Insurance Information, HIPAA & Financial Policy

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Financial Policy & Patient Responsibility

Patient’s Responsibility:

  • To know their insurance policy. Patients should be aware of their benefit coverage including which physicians are contracted with their plan, covered and non-covered services, authorization requirements, and costs share information such as: deductibles, co-insurance, and copayments. If you are not familiar with your plan coverage, we recommend contacting your carrier directly.
  • · To obtain a referral from their Primary Care Physician (PCP) and/or obtain authorization for treatment from their insurance prior to receiving services if that is a requirement of their plan. Any non-covered services are the financial responsibility of the patient.
  • To inform the front office of any changes to insurance and provide updated insurance cards.
  • To promptly pay any accrued charges labeled “patient responsibility” as indicated by their insurance carrier to our biller, Efficient Medical Billing Service (EMBS).
  • To facilitate in claim payments by contacting their insurance carrier when claims have not been paid.
  • · Should you need to cancel or change your office visit appointment you will be subject to a $50.00 late cancel fee for Naturopathic services, or a $45.00 late cancel fee for Massage appointments. All other services incur a $30 late cancel fee if you do not give 24 hours advanced notice. By signing below, I agree that I am financially responsible for any charges incurred for missed appointments in which I did not give the required advanced notice. I agree to the secured storage of my credit or debit card information to take payment for these fees, should I incur them.

Financial Policy Acknowledgement:

I have read and understand the above financial policy. I understand and agree that regardless of my insurance coverage, I am ultimately responsible for the balance due on my account for any and all services rendered; including non-covered services and/or supplements that are denied by my insurance carrier. I understand that payments can be made by check, credit or debit card to “Holistic Health Clinic”. I agree the if my account is referred to a collection agency or attorney, I will be responsible for all costs of collection on my account including but not limited to attorney’s fees, and interest accrued on overdue balances.

HIPAA Compliance

The Health Insurance Portability and Accountability Act, also known as HIPAA, was created in 1996 by the US Congress to protect the privacy of your health information. The act prohibits your health care providers from releasing your health care information unless you have provided your health care provider with a HIPAA release form. 

Unless you have provided a signed release form, your health care providers are prohibited from discussing any aspect of your medical information with anyone who is not directly involved in your care. I understand that a record will be kept of all health services provided to me. This record will be kept confidential and will not be released to others unless so directed by my representative or myself, or unless required by law. I understand that I may look at my medical record and request a copy of it. I understand that my medical record will be kept no longer than seven years after the date of my last treatment. I understand that my practitioner will answer any questions I have. 

PRIVACY POLICY: 

Due to HIPAA Privacy Regulations, our office is required to offer you a notice of our privacy practices. This document lets you know what steps we take in protecting your health information. Please ask the administrative office staff if you would like a copy when you arrive for your appointment. 

By signing, I agree that I have read and understand the above polices and procedures. 

Thank you for taking the time to fill out this form.

Office Hours

Monday

10:00 am - 7:00 pm

Tuesday

10:00 am - 7:00 pm

Wednesday

10:00 am - 7:00 pm

Thursday

10:00 am - 7:00 pm

Friday

10:00 am - 7:00 pm

Saturday

10:00 am - 5:00 pm

Sunday

10:00 am - 5:00 pm

Monday
10:00 am - 7:00 pm
Tuesday
10:00 am - 7:00 pm
Wednesday
10:00 am - 7:00 pm
Thursday
10:00 am - 7:00 pm
Friday
10:00 am - 7:00 pm
Saturday
10:00 am - 5:00 pm
Sunday
10:00 am - 5:00 pm

Location

New Patient Inquiry