Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

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1 Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best service possible. Here are a few of our office policies. Registration: All patients must complete a patient information form before seeing their provider. Nurse Practitioner: Here at Methodist Moody, we take strong consideration about your wait time and the convenience of our patients. Each neurosurgeon is accompanied by their very own nurse practitioner to also see patients in clinic and surgery. Our nurse practitioners are highly qualified to carry out your plan of care. You may see the nurse practitioner for post surgery appointments, and if the physician is called away to surgery due to a hospital trauma. If you do not wish to see the nurse practitioner, please notify the front desk representative. Your appointment will be rescheduled to the next available appointment to see the physician. Charges: Full payment is due at the time services are rendered unless other payment arrangements have been made. For patients without insurance, payment is due at the time of service. Copays and balances are expected at the time of service. After 90 days, outstanding balances will be referred to a collection process. Billed charges not covered by insurance are the insured s responsibility. Delays in insurance processing occur when insurance information is not provided in a timely manner. Such delays may also result in insurance not covering care. Whenever insurance denies payment for a service, it is your responsibility to cover the charges, even while you may choose to review your benefits with your insurance provider. Surgery Deposits: A surgery deposit is requested prior to each surgery performed. Our office representative will contact you, to discuss your insurance benefits and your amount of down payment prior to your surgery. NSF/ Closed Accounts: There will be a $35.00 charge added for returned checks. FMLA/DISABILITY Paperwork: We will complete forms for patients that have undergone surgery by our physicians only. Our form fee is $20.00 for each set of forms that requires a physician s signature. This must be paid in full before the paperwork can be picked up or faxed. Please allow 7-10 working days to complete paperwork. Medical forms CANNOT be completed on the same day forms are presented to the office. Non-surgical patients may request their medical records and refer to primary care physician for completion of forms. Medical Records: All Medical Records are processed by HealthMark and take seven business days to process. All medical requests must be in writing. Please contact our health information coordinator for all (P) Ex (F) Appointments/ No Show: We request 24 hour notice for appointment cancellations. Authorizations for Surgery: Allow up to 14 working days to process routine surgery authorizations. POS Reorder #

2 Insurance: Insurance cards must be available prior to each visit. Please notify our office if there is a change in your insurance plans or coverage. We file claims as a courtesy to our patients and are only responsible for filing claims to contracted insurance companies and the member. Any dispute for unpaid charges from the insurance company will be billed to the member. All patients must have an insurance ID card in order to utilize benefits. Medication Refills: All prescription refill requests should be called into your pharmacy at least five (5) working days before the last pill taken to allow adequate time for approval. Please have your pharmacy fax your request to (214) Allow 24 hours for all requests to be processed. Refills will only be handled during normal business hours, Monday through Friday. Narcotic prescriptions will not be refilled after office hours or on weekends. Behavior: Physical and verbal abuse towards the office staff will not be tolerated. This includes disruptions affecting daily operations within the office as well as offensive behavior on the telephone with office personnel. Abusive behavior towards personnel will result in immediate discharge from the practice. After Hours: Our phone message will provide patients with a number to call our answering service for urgent needs after hours. The answering service will notify the physician on call. Please understand you may not be able to speak directly with your personal physician. It is possible to receive a phone call from the nurse practitioner in most cases. Please note the physician on call will not authorize medication refills or prescribe new medication. If you feel you have a life-threatening emergency, please dial 911 or go to your nearest emergency facility. Feedback: You may receive a patient satisfaction survey from Press Ganey to your address. Please take time to complete and let us know how we are doing. Your opinion matters to us. Notice of Privacy Acknowledgement: Methodist Moody s Notice of Privacy Practices provides information about how Methodist Moody may use and disclose protected health information. You have the right to review the Notice before signing this acknowledgment. A copy of the current notice is posted in the waiting room. The Notice contains the effective date and as provided in our Notice, the terms of our Notice may change. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations, as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent. Your signature also represents acknowledgement of receipt of the MMBSI Privacy Notice, Financial Policy and Patient Rights and Responsibilities Notice. This Privacy Acknowledgement does not give us consent to release records to anyone except to whom is mentioned above. A signed medical release authorization form must be completed prior to us releasing records on your behalf. Thank you for your understanding and agreeing to our Office Policies. We are committed to be an involved member of your Health Care Team working together for your health! Signature of Patient or Guardian Date POS Reorder #

3 Practice Financial Policy Medical Insurance Providing quality medical care to our patients is our primary concern. In order to accommodate the needs of our patients, we have enrolled and contracted with many health plans. With your cooperation and assistance, you should be able to receive all of the benefits offered to you by your health plan allowing our physicians the opportunity to concentrate on caring for your medical needs. In order to facilitate your care, we ask that you read and follow these guidelines. Please bring your insurance card to all office appointments. If you have an HMO or other managed care policy, you must obtain a referral from your PCP as instructed by your insurance company. Due to HMO regulations and restrictions, we may have to cancel or reschedule your appointment until a referral is obtained. Depending on your particular plan, please verify the number of visits permitted. You will be responsible for any visit not authorized. We will collect all applicable co-pays, co-insurance, and deductibles at the time of service. In all cases, our office collects an estimate of your financial responsibility. We submit all claims to your insurance carrier and the insurance company then designated the definitive patient responsibility. We will credit any overpayment in a timely manner. If you have a responsibility greater than what was originally collected, our office will send you a statement for the additional portion. You may contact our Financial Counselor to make arrangements for payment. Third Party Liability Carrier Our practice does not take part in third party liability cases such as an auto accident. We recommend before using your private insurance, to contact the third party carrier to verify the company is willing to reimburse any out of pocket expenses that will occur. We will collect all applicable co-pays, co-insurance, and deductibles according to your insurance plan at the time of service. You may request an itemized receipt to provide to your third party carrier to show proof of payment. Methodist Moody does not file claims through third party liability insurance companies such as auto insurance. Should your medical insurance company deny or request a refund for payments made, all charges will be your responsibility. Worker s Compensation Worker s Compensation claims are handled directly with the carrier and case managers in your recovery. Your recovery and returning to work takes a partnership with you, your case manager, and our physicians. Should your claim be denied or deemed not compensable by the worker compensation carrier, all charges will be your responsibility. If you have sustained an injury on the job and have a worker s comp claim, Texas Worker s Comp Commission bylaws prohibit us to accept your private insurance nor can we accept any payments for your office visit. Self Pay Payment is expected at the time services are rendered. However, treatment decisions are based solely on the patient s medical needs. MMBSI will not deny critical care to anyone due to their inability to pay or lack of insurance. Patients who have financial constraints should speak to a financial counselor for assistance. Methodist Moody North Parkway, TX Southwest / Duncanville, TX 75237, TX POS Reorder #

4 Methodist Moody Notice of Privacy Rights Each time you visit Methodist Moody, a record of your visit is made. Typically, this record contains your symptoms, examinations and test results, diagnosis, and a plan for future care and treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment Means of communication among the many health professionals who contribute to your care Legal document describing the care you received Means by which you or a third party payer can verify that services billed were actually provided Tool in educating health professionals Source of data for medical research Source of information for public health officials charged with improving the health of this state and the nation Source of data for our planning and marketing Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. Methodist Moody are required to: Maintain the privacy of your health information Provide you with this notice as to our legal duties and privacy practices with respect to your information we collect and maintain about you Abide by the terms of this notice Notify you if we are unable to agree to a requested restriction Accommodate reasonable requests you may have to communicate health information by alternative locations. We reserve the right to change our practice and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have provided us. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization North Parkway, TX Southwest / Duncanville, TX 75237, TX POS Reorder #

5 Methodist Moody Patient Rights and Responsibilities We consider you a partner in your care. When you are well informed, participate in treatment decisions, and communicate openly with your doctor and other health professionals, you help make your care as effective as possible. Methodist Moody, encourage respect for the personal preferences and value of each individual. It is our goal to assure that your rights as a patient are observed. You and your family have the right to access an interpreter if you are deaf or do not speak or understand English. All patients have a right to refuse a recommended treatment, to the extent permitted by law, and to be informed of the medical consequences of this action. All patients are responsible for their own actions if they refuse treatment or do not follow the physician s recommendations. All patients have the right to every consideration of privacy. Patients are responsible for being considerate of the privacy of other patients. Telephones, television, radios, and lights should be used in a manner agreeable to others. All patients have the right to expect that all communications and records pertaining to their care will be treated as confidential, except in cases such as suspected abuse and public health hazards, when reporting is permitted or required by law. All patients have the right to receive an explanation of their bill, regardless of the source of payment. Patients have the responsibility to provide information necessary for claim processing and to be prompt in payment of their bills. All patients have the right to know the rules and regulations that apply to patient care and conduct and are responsible for following those rules and regulations. All patients have a right to receive an explanation of their treatment program and to ask for further clarifications if the course of treatment is not understood. Patients have the responsibility to cooperate in their treatment program North Parkway, TX Southwest / Duncanville, TX 75237, TX POS Reorder #