Welcome to acrm! 1 ACRM
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1 1 ACRM Welcome to acrm! Thanks for making an appointment for your x-ray test (HSG or Hysterosalpingogram). It will help your doctor evaluate whether there are problems with your fallopian tubes or uterine cavity. We will forward the result directly to your doctor after completing the study. We perform this test at our main Perimeter office (5909 Peachtree Dunwoody Rd, suite 720, Atlanta, 30328). The following pages outline what you ll need to know about doing this test. Beyond basic medical care and the full range of Assisted Reproductive Technologies (IVF, Donor Egg, Frozen Egg), we also offer psychological support, in-house acupuncture, and nutrition services should you need them. To make things easier and more successful for you, we have 3 locations, 6 physicians, 14 nurses, 3 embryologists and whole team of support staff available to you. Our website provides more information about us ( We look forward to your visit! Lisa Hasty, MD Andre Denis, MPH, MD Jim Toner, MD, PhD Robin Fogle, MD Sue Ellen Carpenter, MD David Keenan, MD Kathryn C. Calhoun, MD Steve Gerson, CPA Chad Johnson, PhD, HCLD
2 2 ACRM acrm Office Hours, Locations, Emergencies Johns Creek 6470 East Johns Crossing, suite 200 Johns Creek, GA OPEN: Mon to Fri, 8 am to 4 pm Perimeter (main) 5909 Peachtree Dunwoody Rd, #720 Atlanta, GA OPEN: Mon to Fri, 8 am to 4 pm Sat, Sun, holidays, 8 am to noon Buckhead 1800 Howell Mill Rd, suite 675 Atlanta, GA OPEN: Mon to Fri, 8 am to 4 pm Note: we are open on weekends and most holidays till noon. Phone: (770) (for all offices)
3 3 ACRM Emergencies: (770) For your visit Prior to your first visit with us, please: Fill out the Patient Information Sheet, and fax to (678) Fill out the Consents & Authorizations and fax to (678)
4 4 ACRM New Patient Information Date: You: Name: Nickname: Age: Occupation: Phones: Cell: Work: Home: Pharmacy: Spouse / Partner (if applicable) Name: Nickname: Age: Occupation: Phones: Cell: Work: Home: Pharmacy: Your Address: Street: City, State, and Zip: Referred by: Current doctor: Practice Name: Address:
5 5 ACRM Consents & Authorizations The following Consents and Authorizations need to be reviewed, completed, and returned by fax, or in person before or at the first visit. FAX to (678) or to: Consent to Communicate Consent to use Electronic Records Obligation to Pay Consent to Verify Insurance benefits Authorization to use Credit Card for billing
6 6 ACRM Name: Date of birth: Consent to Communicate During the course of treatment at ACRM, physicians, nurses, lab personnel, counselors, acupuncturists, nutritionists or administrative staff may have reason to call with information about test results and instructions regarding ongoing care, nutritionists as well as financial aspects of my treatment. I understand that I have the right to modify or rescind my authorization at any time. I certify that each number below is a private and direct number. I hereby grant my permission for ACRM staff to a leave a voice mail message, which may include protected health information at the phone numbers I have provided in the event I cannot be reached. I also grant permission for ACRM to discuss information regarding my care and financial matters with my spouse or partner. Signature: X Date Consent to use Electronic Records I acknowledge and agree that ACRM may convert some or all of my medical records into electronic format and thereafter maintain such medical records only in electronic format. I also acknowledge and agree that Consents (together with my signatures on all such Consents) that are obtained from me may be maintained by ACRM in electronic format. For purposes of obtaining my consent (under O.C.G.A ), I hereby consent to being required by ACRM to receive, recognize, accept, be bound by, and/or otherwise use electronic records and signatures as described herein. I hereby agree that such medical records and Consents and signatures of mine in electronic format are valid and will have the same validity as the hard paper copy thereof. Likewise, facsimiles or scanned images of any signed documents or consents shall have the same validity as the original. I acknowledge that I have carefully reviewed this Consent and understand its content. Signature: X Date Obligation to Pay I hereby make the assignment of all disability, surgical, medical, and major insurance benefits to ACRM and to release any medical information necessary to execute an assignment of benefits. I understand that regardless of any insurance coverage I might have, I am personally responsible for all charges to this account. I further agree that in the event of nonpayment by my insurer, to bear the cost of collection and/or court cost and reasonable legal fees should this be requested. I understand that I am responsible for services rendered and I agree to pay for services at the time of service. I hereby authorize ACRM to release any information acquired in the course of my examination and treatment to my insurance company or to another physician. I direct my insurance carrier to issue payment directly to ACRM. I understand that I am financially responsible to ACRM for any balance not covered by my insurance carrier. The cost of collection (35%) will be added to all delinquent accounts at the time they are placed with a collection agency. I/We understand and agree that any credit granted shall be paid promptly in accordance with terms and agreements, that ACRM may add one and one half percent (1 ½%) per month to any balance owed, and in the event of default to pay collection charges and/or attorney fees. Signature: X Date
7 7 ACRM Name: Consent to Verify Insurance Benefits and Bill Insurance I hereby give my permission for ACRM (or a third party company who it designates) to obtain from my health insurance and prescription benefits companies full and complete health insurance and medication coverage information, including, but not limited to coverage related to infertility (if applicable). I give my permission to ACRM to forward the information provided above to the third party company for benefit verification purposes. I give my permission to the third party company to forward health insurance benefit and prescription benefit information obtained from my insurance companies to ACRM. A facsimile or scanned image of this signed document shall stand as an original. I also hereby give my permission to ACRM, to forward certain medical information it deems necessary to an outside third party who it designates to determine my eligibility to participate in certain patient financial service programs that are made available through ACRM. These include, but are not limited to the IntegraMed Attain Program. Patients are in no way required to participate in these programs. I likewise give my permission to the third party company to forward to ACRM my prequalification status. The health insurance and medication benefits verification program and the financial services prequalification program is offered as a courtesy and without charge. Neither ACRM or the third party company performing the insurance verification of benefits and prequalification for patient financial service programs shall have any liability to any person with respect to assistance provided under the program, including if insurance or the reimbursement coverage is verified under the program, but coverage is later denied; or if the prequalification is preliminarily granted but subsequently not granted. Patients are encouraged to confirm all insurance or reimbursement coverage determinations made under the program directly with their insurance carrier or other reimbursement source. HEALTH INSURANCE CARD: Insurance Company: ID number: Group number/name: Insured s Employer: Policy number: Phone number for benefits determination: X Date Date of Birth: Social Security #: Attention All Aetna Patients - You may be required to register with Aetna's Infertility Hotline. If a patient is required by Aetna to register with the Aetna Infertility Hotline but fails to do so, Aetna will not consider paying for any services, and all services rendered will be your responsibility. Call to obtain your registration number, and complete the below: My Aetna Registration No. is: OR I called Aetna and was informed that I am not required to register.
8 8 ACRM Name: Date of birth: Consent to use Credit Card for billing As part of our effort to control the cost of health care for our patients and streamline our administrative processes, we have established an automated credit or debit card system for your convenience. This will simplify payment of your potential co-pays, deductibles, or any non-covered services. This system is similar to what car rental agencies and hotels do worldwide. Our system will securely hold your card information until your health insurance processes your claims and mails you their Explanation of Benefits which outlines your financial obligation. Your card will only be charged once your insurance company specifies your exact responsibility. It is the intent of this policy to save you time and simplify the billing process. This authorizes ACRM to charge your card (listed below) for any balances due on your account. You will always be advised via a printed ACRM statement of any charge made to your card via this authorization. If the balance is less than $250, we will charge your card and mail your receipt. For balances above $250, we will contact you by or phone regarding the balance due, then charge your card if we have not heard back from you by the close of the next business day. You: X Date Name imprinted on card: Card Type: CREDIT: -VISA MasterCard [others currently not accepted] Credit Card number: Expiration date: Billing Address: (street) (city, state, zip We re looking forward to meeting with you soon, and hope to help assist you in your family building efforts. Remember, we re here because of you, and more importantly, we re here for you!
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BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome! Thank
Georgia Bulk Requestor Re-certification Package Must Include:
Georgia Bulk Requestor Re-certification Package Must Include: Georgia Department of Driver Services Application for Motor Vehicle Records (1 page) Facilitator Addendum to the Bulk Requestor Agreement (1
Patient Billing. Questions/ Answers. Assistance Programs
Patient Billing Questions/ Answers Assistance Programs Table of Contents Patient billing: an introduction... 1 Patient financial responsibilities... 2 Our promise to you... 3 Frequently asked questions...
CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DIVISION OF TEMPORARY DISABILITY INSURANCE CLAIM FOR DISABILITY BENEFITS (DS-1) DETACH THIS PAGE AND KEEP FOR YOUR RECORDS CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes