Updated as of 05/15/13-1 -

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1 Updated as of 05/15/ GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to give you a clear understanding of our office protocols and further enhance our professional relationship. Please review and initial each of the following policies and sign at the bottom of the page. HMO REFERRALS: If your insurance policy requires a written authorization or referral for a medical specialist from our office, you must notify the clinic five (5) business days prior to your specialist appointment to ensure that the authorization or referral is received prior to your visit with the specialist. PRE-CERTIFICATION: Some insurance companies require pre-certification for the more expensive radiological procedures. If your insurance requires pre-certification of a non-urgent procedure, the procedure may be delayed. Pre-certification may take up to three (3) business days to obtain due to constraints placed on the clinic by the insurance company. MEDICATION REFILL: When you need a prescription refill, please contact your pharmacy before calling the clinic. The pharmacy will then call the Quiroz Adult Medicine Clinic, PA with the necessary information to fill your prescription. This step ensures that you are prescribed the correct medication, from the correct pharmacy and prevents refill errors. Routine medication refills make take up to 24 hours to approve, but are generally completed by the end of the business day. There may be a delay on a given refill if your insurance company requests additional information regarding the prescription. Holidays and weekends may also delay the fulfillment of a prescription refill; for this reason, please give appropriate advance notice of your refill requests. Routine refills will not be processed after business hours or on weekends. AFTER HOURS CARE: In the case of a non-life-threatening emergency, please contact the office at the main phone number, (210) The answering service will notify the provider on call. If you feel that your situation is life-threatening, please visit the nearest emergency room or urgent care facility to receive immediate medical attention. Please contact QAMC on the following business day to schedule a follow-up appointment regarding this emergency visit. After-hours calls deemed non-urgent may incur a fee. HOSPITAL CARE: If you are admitted to the hospital for any reason, QAMC utilizes the hospital s on-call physician to attend to your needs. The hospitalist is a primary care specialist who has focused their practice on inpatient care, while QAMC has limited its practice to out-patient care. At the time of your admission to and discharge from the hospital, the hospitalist will send the clinic a summary of care. Follow-up care at the clinic is recommended after discharge from the hospital.

2 Updated as of 05/15/ FORMS: Our office charges a minimum of $25.00 for letters and forms from other facilities that need to be completed by your primary care physician. These forms include, but are not limited to the U.S. Department of Labor Family and Medical Leave Act, and school sports physical forms. Please complete all the demographic information before bringing us the form. MEDICAL RECORDS RELEASED TO PATIENT: According to state guidelines, the minimum charge for the release of medical records to a patient is $ FINANCIAL POLICIES Quiroz Adult Medicine Clinic is committed to providing you and your family with the best available health care. The following is provided in an effort to help you understand the policies of the clinic. These policies are in place to help ensure that your receive quality care each time you interact with the staff and providers of the clinic. Please review and initial each of the following policies and sign at the bottom of the page. As the recipient of service, you are ultimately accountable and responsible to make payment for all services rendered to you. By agreeing to accept service, you also accept the responsibility to pay the balance, if any, left over after your insurance company has made payment. You will also be expected to accept full responsibility for all charges incurred for services on days that you cannot produce proof of insurance that certifies your eligibility with the plan. Your insurance policy is a contract between you, your employer and the insurance company. The clinic s relationship is with you, not your insurance company. For this reason, Quiroz Adult Medicine Clinic, PA will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance, and usual and customary charges. As your medical provider, the clinic will only supply factual information to facilitate claim processing. Fees for services are due at the time the service is rendered. If there is a copayment or unpaid balance, the patient will be asked to render payment prior to the visit. Fees that are determined based on services rendered will be collected at the end of the visit. For your convenience, Quiroz Adult Medicine Clinic, PA accepts cash, checks, money order, Visa, MasterCard and Discover as forms of payment. It is your responsibility to promptly remit to Quiroz Adult Medicine Clinic, PA any payment made directly to you by your insurance company for services billed by the Quiroz Adult Medicine Clinic, PA. If your insurance company does not remit payment within 60 days of service due to incorrect or lack of information supplied by you, the balance for the service will be transferred to you and therefore be due by you, the patient.

3 Updated as of 05/15/ Once your insurance has reimbursed Quiroz Adult Medicine Clinic, PA, we will send you a statement of your responsibility. The bill is payable upon receipt. If the bill is not paid in full within 90 days and you have not contacted Quiroz Adult Medicine Clinic, PA regarding payment, your account will be considered delinquent. As a last resort, we may turn the account over to a collection agency. If so, their fee of 50% of the outstanding balance will be charged to the patient. Secondary insurances will not be billed by this office. This is in order for the staff of Quiroz Adult Medicine Clinic, PA to focus their attention on providing you with the greatest quality care. You are responsible for submitting the claim to your secondary insurance company. If you have Medicare Part B as your primary insurance and Medicare submits your claim to the secondary carrier, you will not be held responsible for this payment. At Quiroz Adult Medicine Clinic, we understand that financial problems may affect timely payment for services rendered. We encourage you to communicate any such problems to the clinic staff, so that we may assist you in keeping your account in good standing. I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR MY ACCOUNT. I ACKNOWLEDGE THAT I HAVE READ THE FINANCIAL POLICIES AND AGREE TO TERMS OF PAYMENT DUE.

4 Updated as of 05/15/ AUTHORIZATION TO RELEASE INFORMATION It is the physician s responsibility to ensure that the physician patient relationship is confidential. The Privacy Statement of Quiroz Adult Medicine Clinic, PA is the basis for how we treat your Protected Health Information (PHI), HIPAA allows physicians to use their professional judgment on disclosing certain PHI to family, friends, etc. without an authorization. Please review and initial each of the following policies and sign at the bottom of the page. I authorize Quiroz Adult Medicine Clinic, PA to release all medical information (including but not limited to: information on psychiatric conditions; sickle-cell anemia; alcohol and drug abuse; and HIV or communicable diseases) requested by my health insurance carrier, Medicare, or any other third party payers. I authorize Quiroz Adult Medicine Clinic, PA to release and receive all medical information to and from my specialty physicians. I authorize Quiroz Adult Medicine Clinic, PA to contact my insurance company or health plan administrator to obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to Quiroz Adult Medicine Clinic, PA. Quiroz Adult Medicine Clinic, PA honors the important role that families, friends, and other loved ones play in supporting our patient s healthcare and treatment. At the same time, the clinic is committed to protecting the patient s privacy as well as complying with state and federal law. Accordingly, disclosure to other people, even family, must remain a decision that rests with the patient. By signing the form below, I authorize the Quiroz Adult Medicine Clinic, PA to disclose the protected health information as described below. The protected health information in my medical records may be released and/or discussed with the following persons (any records excluded from this release will be noted): Exclusions, if any:

5 Updated as of 05/15/ PREVENTIVE CARE VISITS In an effort to best serve you, the following is an explanation of preventive care visits; what they entail, and how they are useful in helping you attain and maintain a high level of health. The preventive exam is also known as a physical. Some insurance companies distinguish the physical exam from the well-woman exam, while others do not. The preventive care visit or physical is a healthy visit. It is a time for you to come to the doctor to: - review your current health status; - discuss strategies to screen for certain health problems that may be silent or underlying; - recommend strategies to improve your current health; - And discuss methods to prevent future injury or illness. Patients will often attend this visit with a list of concerns: various symptoms that have become bothersome or worrisome. In order to provide you with the best care possible, it is impractical to try to address all of the preventive needs and these concerns in the same visit. Additionally, most insurance companies will not cover a preventive visit which is, by definition, a well visit, on the same day as a sick visit because they are, by definition, mutually exclusive. The few companies that will pay for both will expect the patient to be responsible for a second co-payment on the same day. It is for these reasons that the policy of Quiroz Adult Medicine Clinic, PA does not allow for both a preventive visit on the same day as a sick visit. Should you have an appointment scheduled for a well visit and find that you are sick, the providers will address the illness and reschedule the preventive exam. As stated in the financial policy, Quiroz Adult Medicine Clinic, PA will provide the insurance company with information that is factual. If the visit was a preventive visit, the clinic will bill it as such. If concerns regarding symptoms that are possibly an illness are addressed, the office will bill for a routine or sick visit. It is your responsibility to understand your insurance company s policy regarding payment for the well visit as opposed to the sick visit.

6 Updated as of 05/15/ NO-SHOW POLICY Thank you for the confidence you have placed in Quiroz Adult Medicine Clinic, PA for the care of your medical needs. The providers at this clinic will prescribe an individual plan of care for your condition. This treatment plan will require commitments from both yourself and your provider. Once this treatment plan is agreed to, the provider will need to monitor your progress and may require you to schedule regular clinic visits. In order to ensure the availability of appointments for those who require medical services, the clinic has established a no-show policy to protect the time of both yourself and other patients at Quiroz Adult Medicine Clinic, PA. A No-Show appointment occurs when you do not show up for a schedule appointment, arrive after the next appointment has already begun, or you cancel your appointment with less than a business day s notice. If you fail to show up or cancel an appointment, the office will send you a notice informing you of the incident. Monitoring your condition is very important to the successful outcome of your care. It is for this reason that if you fail to show up to the clinic at your appointed time, Quiroz Adult Medicine Clinic, PA may charge a $25 fee for routine office visits and $50 for preventive care or physical exam appointments that are not kept. If this problem persists, you may be discharged from the practice. We ask that if you are unable to make your scheduled appointment, you please call the office at least 24 hours in advance. The staff will make every effort to reschedule your appointment at a time that is convenient for both you and the provider based on the urgency of the appointment.

7 Updated as of 05/15/ TELEPHONE NOTIFICATION OF TEST RESULTS Please note that in the event of an abnormal test result, a message will be left on your answering machine instructing you to contact the office if you cannot be reached. The nature of the test results will not be left on an answering machine or with anyone other than the patient. Please initial ONE of the following regarding your preference concerning normal test results: I authorize the staff at Quiroz Adult Medicine Clinic, PA to leave a message that test results are normal on the answering machine or with whoever answers the phone at the number listed below. Phone number: I prefer to have the staff at Quiroz Adult Medicine Clinic, PA leave a message for me personally to call the office regarding all lab results. In this case, a message will simply request the patient call the clinic regarding the test results. *Please note, normal mammogram results are sent by mail to the patient by the radiologist and are not routinely called. With the exception of mammogram results, if you have not received a call from our office within three (3) business days of the test date, please contact the office to inquire about the results.