BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES

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1 BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established specific financial policies in reference to services rendered by Bowling Green Internal Medicine and Pediatrics, Associates. Our office does not accept walk in appointments. Appointment times over 20 minutes late will have to be rescheduled for another date and time. The financial policies are as follows: MEDICARE PATIENTS On January 1 st of each calendar year Medicare requires that a $ deductible be satisfied prior to benefits being paid at 80% of the reasonable and customary amount. If you have not met your deductible prior to your office visit you will be responsible for your charges until your deductible is met. Once the deductible is satisfied you will be responsible for 20% of your charges. The only exception to this is a secondary supplemental plan that would cover the 20% of your charges. Please present all insurance cards to the front office upon your initial visit so this can be identified. If our office is aware that certain services are considered non-covered by Medicare, you will be asked to sign an Advance Beneficiary Notice that we informed you of any non covered service and your financial responsibility. MEDICAID PATIENTS You must have your Medicaid card available upon each visit to the office so that we can verify eligibility for that time period. If you do not have your Medicaid card available your appointment will have to be rescheduled for another date and time. COMMERCIAL INSURANCE PATIENTS Upon your initial visit to our office please present your insurance card. Our office will call your insurance to verify coverage and eligibility. You will be responsible for any applicable deductibles, co-pays and non-covered services that are required to be paid at the time of service. Insurance claims are billed to your insurance company as a courtesy; however, it is your responsibility to understand your insurance benefits as well as how your insurance processes and pays your claims. SELF-PAY PATIENTS Our office does not accept new self-pay patients unless approved by the physician and prior arrangements have been made. Payment will be required at the point of service. WORKMAN S COMPENSATION Any patient being seen for a work related injury must have prior written approval from the workman s compensation carrier prior to being seen. Our office must be able to verify the reason for the visits as well as coverage for the date of service. The information should include the insurance company name, address, phone number, adjuster s name, injury date and workman s claim number. We cannot schedule the patient without this information. Failure to present this information on the day of the visit will result in rescheduling the visit for another date and time. THIRD PARTY LIABLITY CLAIMS Third party liability claims will be considered on a case-by-case basis. Prior to the visit in our office we will require all necessary billing information in writing. This information will include the names of all involved parties; complete insurance information, adjusters name and claim number if applicable. If you have attorney representation this information must also be provided. REFERRALS Please be aware of our office policy in reference to referrals. If your insurance company requires a referral when seeing another physician or specialist, please allow us 7 days notice to prepare your referral form for a non-emergency visit. If the 7 day notice is not received or another physician s office calls the day of the appointment, in a non emergency situation, the referral will be denied and you will be responsible for the visit. All non-emergent referrals will be done on the Monday prior to your visit with the other physician or specialist. All emergency referrals will be handled on a case-by-case basis. Please notify the office as soon as possible in an emergency situation. As a courtesy, we would like to inform you that various insurance companies will not allow us to do a back dated referral. It is very important that you keep us informed when a referral is needed for any reason. It is the responsibility of the patient, or insured if a minor child is involved, to inform our office if a referral is needed due to the various number of insurance companies and policies that have different levels of benefits. This financial policy will be strictly adhered to with the only exceptions being when prior arrangements have been made. Please direct any billing questions to the billing supervisor or the office manager. Signature Responsible Party or Parent of Minor Child Signature AUTHORIZATION FOR MEDICAL/SURGICAL TREATMENT I hereby authorize S.Augusta Mayfield, MD, and/or Paul Kniery, MD, and/or Kelly Kries, MD, and/or Ashley Parrigin, APRN, and/or Emily Cope, APRN, to administer such anesthetics and/or Medications and to perform such operations and/or procedures, and to admit to such hospital as may be deemed advisable in diagnosis and treatment of this patient. I have custody and/or responsibility for this patient and I have read the above and understand fully the contents thereof. Signed Relationship to Patient Date INSURANCE AUTHORIZATION AND ASSIGNMENT I hereby authorize payment of insurance benefits to be made directly to S.Augusta Mayfield, MD, and/or Paul Kniery, MD, and/or Kelly Kries, MD, and/or Ashley Parrigin, APRN, and/or Emily Cope, APRN, for services rendered. I also herby authorize S.Augusta Mayfield, MD, and/or Paul Kniery, MD, and/or Kelly Kries, MD, and/or Ashley Parrigin, APRN, and/or Emily Cope, APRN, to release records pertinent to my care to referring physicians, and other healthcare facilities and my insurance company. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. Signed Relationship to Patient Date HIPAA By signing this form, you consent to our use and disclose of protected health information about your for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH Act). I understand that the HIPAA policy is posted in both lobbies, and a copy will be made available to me upon my request. Signed Date Date

2 BOWLING GREEN INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES REGISTRATION FORM PERSONAL INFORMATION Date: Physician: Patient Name: Address: CITY ST ZIP Home Phone: Work Phone: Cell Phone: May we leave a message: Yes No Date of Birth: Age: Social Security Number: Patient Sex: (Please circle) Male Language: Female Race: Ethnicity: Address: Mother (Guardian): Social Security: DOB: Address: CITY ST ZIP Father (Guardian): Social Security: DOB: Address: CITY ST ZIP Guardian Employer Name: Employer Address: CITY ST ZIP Emergency Contact: Phone: Relation: Pharmacy Name: Pharmacy Number: INSURANCE INFORMATION Primary Insurance: Phone: Subscriber Employer: Phone: Subscriber Name: DOB: Sex: Relation to patient: Social Security Number: Subscriber ID: Group #: Secondary Insurance: Phone: Subscriber Employer: Phone: Subscriber Name: DOB: Sex: Relation to patient: Social Security Number: Subscriber ID: Group #:

3 BOWLING GREEN INTERNAL MEDICINE AND PEDIATRIC, ASSOC ASHLEY CIRCLE SUITE 200 BOWLING GREEN, KY LEAD AND TB QUESTIONNAIRE August 3, 2015 Name: Lead Questionnaire: Yes No 1) Does your child live in or regularly visit a house or child care facility built before 1950? Yes No 2) Does your child live in or regularly visit a house or child care facility built before 1978 that is being or has recently been renovated or remodeled? Yes No 3) Does your child have a sibling or playmate who has or did have lead poisoning? TB Questionnaire: Yes No 1) Was your child born outside the United States? Are there close contacts to the child who was born outside the United States? Yes No 2) Has your child been in close contact with someone diagnosed with tuberculosis or has a positive skin test for tuberculosis? Yes No 3) Does your child frequently traveled outside the United States? If yes what country? Yes No 4) Is anyone in the child s household HIV-infected, or have a history of incarceration or use illicit drugs?

4 Patient Name: «FirstName» «LastName» DOB: «DOB» Date: 8/3/2015 9:59 AM Physician: «encdocname» Family History Paternal Grandfather O Asthma O Allergies O Blood Clots O Cancer O Depression Paternal Grandmother O Asthma O Allergies O Blood Clots O Cancer O Depression Maternal Grand Father O Asthma O Allergies O Blood Clots O Cancer O Depression Maternal Grand Mother O Asthma O Allergies O Blood Clots O Cancer O Depression Siblings O Asthma O Allergies O Blood Clots O Cancer O Depression Children O Asthma O Allergies O Blood Clots O Cancer O Depression Father O Asthma O Allergies O Blood Clots O Cancer O Depression Mother O Asthma O Allergies O Blood Clots O Cancer O Depression Maternal uncle O Asthma O Allergies O Blood Clots O Cancer O Depression Maternal aunt O Asthma O Allergies O Blood Clots O Cancer O Depression Paternal Uncle O Asthma O Allergies O Blood Clots O Cancer O Depression Paternal Aunt O Asthma O Allergies O Blood Clots O Cancer O Depression

5 Patient Name: Date: Consent to Treatment of a Minor When Parents/Guardians Are Temporarily Unavailable The undersigned parent or legal guardian of authorizes the person(s) listed below to (Child s Name) consent to treatment of the child, including, but not limited to, emergency, x-ray, anesthetic, or surgical services when I am not immediately available in person, or by a telephone call to (Phone Number) It is understood that this consent is given in advance of any specific diagnosis or treatment and allows the physician/provider to diagnose and treat the child even when the parent or guardian is not present. 1. Person(s) who may consent to treatment (please print): Name: Relationship to Child: Phone: Name: Relationship to Child: Phone: Name: Relationship to Child: Phone: 2. Medical concerns: 3. Known allergies: Name of Parent or Legal Guardian: Relationship to Child: (Print Name) Contact Number(s): Address: City, State, Zip: Signature: Date: This Consent is effective until withdrawn in writing by the child s parent or guardian.

6 1 References available upon request SYN08-067O RSV RISK ASSESSMENT SEASON START OCTOBER Patient s Name: Date: Date of Birth: Gestational Age (GA): Birth Weight: (kg) 1. Will patient be less than 2 years of age at the Start of the season (Born after: 10/01/2011)? Yes No Proceed to Question #2 2. Does patient have Chronic Lung Disease (CLD/BPD), hemodynamically significant Yes No Congenital Heart Disease (CHD), or other Proceed to Question #3 serious conditions that compromise pulmonary or immune function (other than prematurity)? 3. Was patient born prematurely (<35 weeks (GA)? Yes No See Table Below < 28 Weeks Gestational Age Less than 1 year old at the start of the season (Born after: 10/01/2012) Weeks Gestational Age Less than 6 months old at the start of the season (Born after: 04/01/2013) Yes No Yes No Weeks Gestational Age Less than 6 months old at the start of the season WITH additional risk factors 1 (check all that apply) (Born after: 04/01/2013) Yes No Daycare attendance (Definition: >2 unrelated children for >4 hr/week School age siblings Exposure to environmental air pollutions Severe neuromuscular disease Congenital abnormalities of the airways Low birth weight (<2,500 g) Multiple birth Exposure to environmental tobacco smoke Crowded living conditions Family history of wheezing Young chronological age (<12 weeks) Other This form is intended for use in assessing infants for risk of acquiring severe RSV disease. The form has been provided as a guide only and is not intended to be a substitute for or an influence on the independent medical judgment of the physician.

7 Bowling Green Internal Medicine & Pediatric Associates 1701 Ashley Circle Suite 200 Bowling Green, KY Phone (270) Fax (270) Notice of Privacy Practices and Patient Consent For Use and Disclosure of Protected Health Information PATIENT NAME DATE I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information. I understand that Bowling Green Internal Medicine and Pediatric Associates may use or disclose my protected health information for treatment, payment or health care operations which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization. Bowling Green Internal Medicine and Pediatric Associates has a detailed document called the Notice of Privacy Practices. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information. I understand that I have the right to read the Notice before signing this agreement. If I ask, Bowling Green Internal Medicine and Pediatric Associates will provide me with the most current Notice of Privacy Practices. My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Bowling Green Internal Medicine and Pediatric Associates to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Bowling Green Internal Medicine and Pediatric Associates has taken action relying on this consent. SIGNATURE (Patient or Legal Custodian/Authorized Representative) Relationship to Patient if signed by another party DATE DATE You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting: BG Internal Medicine & Pediatric Associates, 1701 Ashley Circle Suite 200, Bowling Green,KY 42104, Phone (270) Fax (270) or via our website at

8 Patient Authorization to Release Medical Information / / Patient Name (Print) SS or Health Record Number Patient DOB I authorize (practice/physician s name) to use or release/disclose my health information as described below. Please identify the information to be released: Please release my entire record -OR- Please release only the following information (check appropriate boxes and include other information where indicated): Problem list Medication list List of allergies Immunization records Most recent history Most recent discharge summary Lab results (please describe the dates or types of lab tests you would like disclosed): X-ray and imaging reports (please describe the dates or types of x-rays or images you would like disclosed): Consultation reports (please supply doctors names): Other (please describe): The identified information will be used for the following purpose: My personal records Sharing with other health care providers as needed Other (please describe): Please initial each item below to indicate your understanding. I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand once the information below is released, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure health care treatment. The identified information may be used by or released to the following individual(s) or organization(s): Name: Address: Name: Address: This authorization will expire on (insert date or event): If I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed. Patient Signature (or Signature of Person Completing Form if Not Patient*) *Relationship to patient: Parent Legal Guardian Other: Witness Signature Date Date / / / /

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