Office Policies. It is usual and customary for the fee to be paid at the beginning of each counseling session. Other arrangements will have to be made in advance. Sessions are usually held once a week 0000 00xx XX XX, Xxxxx X-000, Xxxx Xxxxxxx, WA 00000 000-000-0000 fax: 000-000-0000 at first to ensure the greatest change possible. There is a $25 NSF for all checks returned. All requests for copies of your file or amendments are to be made in writing.
Office Policies. E-mail data may be unsecured and result in health information being distributed to unknown third parties for which EFM is not responsible. Use of the secured patient portal is the preferred route of communication for routine matters. Phone call is the preferred route of communication for urgent matters. EFM does not provide emergency care. There may be times when Dr. Black is unavailable. If a health matter is urgent I agree to seek care at an urgent care or emergency room. The preferred urgent care for Empower Family Medicine is Urgent Care at Druid Hills 0000 X Xxxxx Xxxxx Xx XX Xxxxx X, Xxxxxxx, XX 00000. All prescription refills for chronic medications should be requested at office visits. Routine refills will not be issued by phone, fax or call. For Principal and Patients: I have reviewed the EFM Patient Agreement, Policies and Privacy Practices. I have been given ample time to ask questions regarding its content, and consent to its terms. This agreement is made voluntarily with no urgent medical care need. I understand that these authorizations take effect while Patient is enrolled with Empower Family Medicine, and that Patients or Principals have the right to revoke such authorization at any time by cancellation of the Monthly Enrollment Fee, or by written or verbal request. Patient: Principal: Medical Director: Xxxxxxx Xxxxx M.D. MEDICARE OPT OUT AGREEMENT This agreement ("Agreement") is entered into by and between Empower Family Medicine, LLC, a Georgia professional corporation, owned and operated by Dr. Xxxxxxx Xxxxx, MD, (the "Physician"), whose principal medical office is located at 000X Xxxxxxx Xxx Xxxxx 000 Xxxxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B ("Beneficiary"), who resides at .
Office Policies a. Appointments and Cancellations. Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 48 hours notice (2 business days). If you miss a session without canceling, or cancel with less than 48 hour notice (2 business days), my policy is to collect the amount of the full session. If there is an emergency or illness, please contact me so we can discuss it. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time and you will still be charged the full cost of the session. If I am running late, I will do my best to give you a full session. If I am unable to do so, then a prorated amount of my hourly rate of $115 will be charged. _____ I understand that sessions must be cancelled 2 business days (48 hours) in advance or there will be a charge of $115. (Please initial.)
Office Policies. Medication Refills Once medications have been prescribed your provider will strive to work with you as best as possible to ensure timely refills. It is expected that typically the patient or caregiver needs to give at least 2-3 business days notice that a refill will be needed. This will allow the provider time to review the patient’s chart and determine if a refill can be granted without a clinic visit. Remember that all patients need to be seen at a minimum once every 6 months by their medication provider, with 3 months being a standard interval between visits. It is SPBH policy that a refill typically consists of a full month supply. However, if the SPBH provider is not clinically comfortable with providing a full month refill, they may provide instead only enough medication to last until the next clinic appointment. In the event a patient is leaving SPBH medication services but remaining on the medication (e.g. moving, changing providers) a 2-3 month refill of the medication is typically given, unless deemed not appropriate by the medication provider. Missed Appointments Once an appointment is scheduled, you are allowed to cancel for any reason. However, you will be expected to attend unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. If you fail to attend a scheduled session or cancel a session with less than 24 hours notice, you may receive a charge that equals full payment for a session. If this is a continuing pattern, your care may be discontinued in this clinic. Providers in our practice have full clinic schedules. As a result, you may not always have the ability to reschedule easily for the same week in which you cancelled or missed an appointment. You may not always be able to secure times for your child for after school appointments. However, this office will do the very best that we can to work with you on any scheduling concerns that you may have. This office will provide reminders for appointments via e-mail and/or text as a courtesy. However, please understand that it is still your responsibility to attend sessions when they are scheduled, even if you did not receive the reminder. Please do not rely solely on reminder notifications to ensure your attendance at scheduled appointments. Grounds For Termination Services are provided at the discretion of your treatment provider. Your provider reserves the right to terminate services if either...
Office Policies. APPOINTMENTS/COMMUNICATIONS: Xx. Xxxxxx can be reached at 000-000-0000 to schedule an appointment or for other inquiries. At times, Xx. Xxxxxx may be in session with a client and unable to answer the telephone. If this should occur, please leave a message on our confidential voicemail. Your call will be returned promptly. Please note that email is not a secure form of communication and does not ensure confidentiality. Therefore, we request that it only be used for non-clinical communication (e.g. scheduling appointments, etc.) MISSED APPOINTMENTS/LATE CANCELLATIONS: When you schedule an appointment, the time is reserved specifically for you. If you are unable to keep the appointment or need to reschedule, please do so as soon as possible. Appointments cancelled without at least 48 hours notice may be charged a Missed Appointment/Late Cancellation Fee of $50. Insurance companies do not provide reimbursement for these fees. EMERGENCY SERVICES: We do not provide emergency services. If you are experiencing a life-threatening emergency, please call 911, go to your local emergency room or follow emergency procedures per your insurance carrier.
Office Policies. All administrative and office staff are bound to confidentiality and cannot disclose any information. This becomes especially sensitive when relatives call the office requesting even simple information, such as an appointment time for their spouse. Even under these simplest of situations, office personnel cannot acknowledge they even know the person, nor can they disclose any information. If ongoing contact is to occur with a relative, regarding billing for example, a release of information can be signed, specifying the information you permit to be exchanged. All requests for records must be accompanied by a release of information. It is my policy to keep records for 8 years from when the record becomes inactive.
Office Policies. Appointments Please understand that we reserve time just for you when you make an appointment with us and we know your time is very important. We will do everything in our power to have you in-and-out on time. Likewise, we ask that you respect our time, and the time of other patients. If you are scheduled for an appointment and need to reschedule or cancel, we require 48 hours notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. A $50 fee may be charged to you for any appointment that rescheduled, cancelled or missed without 48 hours notice. For any missed appointment fees collected, Xxxxxx Xxxxxx Healthcare will match the fee and donate the total amount to the charity Xx Xxxxxx has chosen for the quarter. If you are late for your appointment, we may not be able to accommodate you. If you think that you will be late, we do ask that you call as soon as possible so that we may advise you if your late arrival can be accommodated, or if we will need to reschedule you. You may be required to pre-pay for your next appointment if you have an outstanding balance or if you have missed two or more appointments in the last twelve months. For services exceeding $1000 that will have multiple visits, half of your anticipated patient responsibility is due at your first visit or at the time your appointment is made. The remainder is due before being seen for your final visit. For services exceeding $1000 that are only one visit, your full patient responsibility is due at the time of service. Patients Under the Age of 18 Xxxxxx Dental Helathcare is a child friendly practice and we strive to provide an upbeat and comfortable office environment. We ask that you allow your child to accompany our staff through the dental experience. We are all experienced in helping children overcome anxiety and do not want children to have negative dental experiences. Studies and experience have shown that most children over the age of 3 react more positively when permitted to experience the dental visit on their own. Some children may need to seek treatment from a pediatric dentist. Appropriate referrals will be made with the consent of parents. We kindly ask that you refrain from bringing small children to your dental appointment. Children can interfere with our ability to provide you with timely and comprehensive dental care. Children who accompany a parent cannot be brought into the treatment room during your treatment due to x...
Office Policies. Hourly appointments are 60 minutes long and are usually scheduled for once a week. Longer sessions may be accommodated, agreed upon by you and I in advance in the therapist requesting that either (a) the client pays for phone consultation time, or (b) the client increase the frequency of sessions.
Office Policies. I / We hereby authorize mutual exchange of information between providers of Statesboro Pediatric Dentistry 000 X. Xxxxx Street, Statesboro, Ga. 30461. And any other medical or dental provider (except: ) for our child necessary to provide appropriate dental care. • The following information from his/her records can be obtained: X-Rays, Medical and Dental records Indicate nature or extent ofinformation: • The above information is to bereleased for the following purpose only: Dental Treatment and update Medical/Dental history. • I understand that I may revoke this authorization at any time, except to the extent that action has been taken based on this authorization before it is revoked. Initial
Office Policies. It is usual and customary for the fee to be paid at the beginning of each counseling session. Other arrangements will have to be made in advance. Sessions start on the hour and are usually held once a week at first to ensure the greatest change possible. All requests for copies of your file or amendments are to be made in writing.
