Terms and Exclusions. I understand that the Annual Membership Fee payable to PPC Atlanta strictly covers healthcare, amenities and service that are not reimbursed or covered through the Medicare, Medicaid and third-party payers (health insurance) programs. As such, PPC Atlanta will not seek reimbursement for services provided as part of my Annual Membership Fee from Medicare, Medicaid, or any other third-party payer. I understand that I am solely financially responsible for payment of my Annual Membership Fee and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, some of the fees for my annual membership fee may be submitted to my health savings account (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement but please consult a tax expert or your tax preparer for guidance in this regard. I understand that I, or my insurance company, are responsible for all healthcare services that are traditionally covered by a health insurance program. These services exclude the services that are provided under my Annual Membership Fee. Regardless of health coverage, I understand that all co-payment, co-insurance and/or deductibles will apply as defined by my insurance policy. PPC Atlanta will bill my Payor for those services. In the event that the services are not covered by my Payor, I understand that I am responsible for payment.
Terms and Exclusions. 1. The SLA explicitly does not apply to:
Terms and Exclusions. I understand that the Membership Fee payable to HIM strictly covers healthcare, amenities and service that are not reimbursed or covered through the Medicare, Medicaid and third-party payers (health insurance) programs. As such, HIM will not seek reimbursement for services provided as part of your Membership Fees with your medical insurance. I understand that I am solely financially responsible for payment of my Membership Fees and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, some of the fees for my membership fee may be submitted to my health savings account (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement but please consult a tax expert or your tax preparer for guidance in this regard.
Terms and Exclusions. I understand that the Membership Fee payable to HIM strictly covers healthcare, amenities and service that are not reimbursed or covered through the Medicare, Medicaid and third-party payers (health insurance) programs. As such, HIM will not seek reimbursement for services provided as part of your Membership Fees with your medical insurance. I understand that I am solely financially responsible for payment of my Membership Fees and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, some of the fees for my membership fee may be submitted to my health savings account (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement but please consult a tax expert or your tax preparer for guidance in this regard. ATLAS MD Patient History Form Name: Birth date: Marital Status: Occupation: Allergies to Medications, Latex or Dyes □None □ Yes (please list) Medications (Prescriptions, non-prescriptions, vitamins and supplements) □None □ Yes (please list) Surgeries/Hospitalizations/Serious Injuries Year Immunizations N Y N Y Hepatitis B Series Recent Pneumonia Vaccine Gardasil Series Recent Flu Vaccine Chicken Pox immunization or disease Positive TB Screening Health Maintenance No Yes (Year) No Yes (Year) Colonoscopy Bone Density Mammogram Eye Exam Pap Smear Physical Exam Social History No Yes Smoking Pack(s)/day /years □ Quit Alcohol Drinks/day drinks/week Caffeine Drinks/day Recreational Drugs Special Diet If yes describe: Regular Exercise If yes describe: Sexually Active □ Men □ Women □ Both GYN History OB History Age of first mensus: ( ) Menopause □ N □ Y (if yes Age: ) Total Number of Pregnancies: ( ) Regular Periods □ N □ Y Painful Periods □ N □ Y Full Term ( ) Pre Term ( ) PMS □ N □ Y – if yes describe Miscarriages ( ) Abortions ( ) Abnormal Pap: – if Yes approximate date ( ) Tubal ( ) Pain with intercourse: □ N □ Y Content with sex life: □N □ Y Medical History (please check if positive) ENT GENITOURINARY SKIN Eye Problems Urinary Infections Psoriasis Sinus Problems Kidney Disease/Stones Skin Disorders Hearing Loss Erectile Dysfunction Melanoma STD CARDIOVASCULAR Urinary Incontinence Abnormal EKG MUSCULOSKELETAL PSYCH Chest Pain Arthritis/Osteo ADD/ADHD Heart Attack Arthritis/Rheumatoid Anxiety Heart Disease Gout Depression High Blood Pressure Neck/Spinal Problems Memory Loss High Cholesterol NEUROLOGICAL OCD Stroke Concussion Suicidal Thoughts/attempt Peripheral Vascular Disease Headache...
Terms and Exclusions i. No warranty applies to any Hardware that is: (i) returned without Rubrik’s prior written authorization pursuant to subsection 2 above; (ii) handled, transported, installed, operated, maintained, stored or used improperly, or in any manner not in accord with the Documentation, the Policy, or Rubrik's written instructions or recommendations; (iii) repaired, altered or modified other than by Rubrik or its authorized service provider; or (iv) no longer covered by the applicable Hardware Warranty due to the expiration of the applicable Term or Hardware Warranty Period. Additional charges may apply for support provided outside the applicable Warranty Period or for excluded repairs or error corrections to the extent not otherwise covered under any Hardware Warranty.
Terms and Exclusions. I understand that the Annual Membership Fee payable to PPC Atlanta strictly covers healthcare services that are not consistently reimbursed or offered through the Medicare, Medicaid and third-party payors (health insurance) programs. As such, PPC Atlanta will not seek reimbursement for services provided as part of my Annual Membership Fee from Medicare, Medicaid, or any other third-party payer. I understand that I am solely financially responsible for payment of my Annual Membership Fee and that this fee is not reimbursable by my private insurance carrier, Medicare or Medicaid. However, the fees for my annual membership fee may be submitted to my health savings account 3 First degree family members include spouse or domestic partner, parent, sibling or child 4 If terminating from the program you must sign a HIPAA compliant request to have your records transferred to your new physician. One copy of your records will be provided to your physician at no charge. Any additional copies of your records will be charged for at then current rates. 5Failure to renew or to make quarterly payment in a timely fashion will be taken as your decision to immediately establish yourself with a new physician. Xx. Xxxxxxxxxx will provide emergency care only for 30 days after your termination from the program. After this time Xx. Xxxxxxxxxx will no longer be responsible for any aspect of your medical care and you should see your new physician for all medical issues. You and/or your insurance company as the case may be, will be responsible for any charges incurred for emergency care provided during this time. (HSA), medical savings account (MSA) or flexible benefits account (FBA) for reimbursement. I understand that I, or my insurance company, am responsible for all healthcare services that are traditionally covered by a health insurance program. These services exclude the services that are provided under my Annual Membership Fee. Regardless of health coverage, I understand that all co-payment, co-insurance and/or deductibles will apply as defined by my insurance policy. PPC Atlanta will bill my Payor for those services. In the event that the services are not covered by my Payor I understand that I am responsible for payment.
