Pharmacy Information:
INSURANCE INFORMATION:
PRIMARY INSURANCE GUARANTOR
I authorize the release of any medical information necessary to process this claim and authorize payment of medical benefits from any Insurance company to Hameed Peracha, MD for his services. The undersigned agrees to pay all charges for services rendered and do hereby become legally responsible for any uninsured balance. In the event of collection procedures are necessary, ali costs including attorney's fee will be patient's responsibilities.
Do you currently have any problems in the following areas? if "YES", please provide details in the space below
FAMILY HISTORY
SOCIAL HISTORY:
Welcome to our Practice . We would like to provide you the best and most comprehensive care. Please read our office policy so we may better serve you.
REFERRAL:
Your insurance may require you to have a referral from your primary care Physician. if your plan requires a referral it is your responsibility to obtain it from your primary care doctor and bring it to the day of appointment.
MEDICAL RECORD:
Patients requesting copies of their medical records must contact the office at least one week in advance, personally pick up the copied records and sign a release/pick up form. We charge$2.00 Per page and $10.00 Handling fee for all copied records..
RETURENED CHECKS:
You will be charged a $15.00 for any returned/cancelled checks..
CO-PAYMENTS:
Co-payment and deductible must be paid at the time of the office appointment upfront..
PRESCRIPTION REFILL:
Please allow atleast 24 to 48 hours to complete your request .
RESULTS:
Results from procedure will be discussed during follow up visit.
REFRECTION FEE:
refraction is an essential part of an eye examination that will help us determine is a patient is in need for glasses. These measurements are not covered by most insurances. if this service is not cover, there will be a $44.00 fee and you will be responsible for this payment.
APPOINTMENTS & CANCELATIONS:
Patients arriving more than 25 mins late will be accomodated besed on the schedule. please give us the courtesy of cancelling office appointments at least 24 hours in advance, $25.00 will be billed for no show . Please provide two weeks' notice for cancellation of any schedule surgery , failure to do so will result in $200.00 fee and will be billed to you .
Our notice of Privacy Practices provides information above how we may use and disclose protected
health information about you. The notice contains a Patients Right section describing your right under
the law. You have the right to review our Notice before signing this consent. The terms of our Notice
may Change. If we change our Notice, you may obtain a revised copy by contacting our office. .
You have the right to request that we restrict how protected health information about you is used or
disclosed for treatment, payment and health operations. We are not obligated to agree to this
restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you
for the treatment, payment and health care operations. You have the right to revoke this consent, in
writing, signing 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 with the Health Insurance
Portability and Accountability Act of 1996 (HIPPA).
The Patient understand that:
• Protected health information may be disclosed or used for treatment, payment and health care
operations.
• The practice has a Notice of Privacy Practices and that the patient has the opportunity to review
this notice.
• The practice reserves the right to change the Notice of Privacy Practices.
• The patient has the right to restrict the use of their information, but the practice does not have
to agree to those restrictions.
• The patient may revoke this Consent in writing at any time and all future disclosures will then
erase.
• The practice may condition treatment upon the execution of this consent.
