Routine Physical Exam Visits Policy
Unfortunately, most insurance companies will not cover routine physical examinations and sick (symptomatic) office visits on the same date of service. If you have an issue that requires treatment two separate visits will be required. We realize the inconvenience this may cause and regret that insurance company’s payment policy has led us to make this business decision. Your understanding in this matter is appreciated.
Missed Appointment Policy
When an appointment is scheduled, a time slot is reserved for your visit. As a courtesy, we will try to make a reminder call. However, it is ultimately the patient’s responsibility to remember the time and date of the appointment. It is also patient’s responsibility to know your co-pay/deductible/co-insurance amount, and to be prepared to pay at the time of service.
In an effort to provide quality care and service to our patients, a 24 hour prior notice is required when canceling or rescheduling an appointment. Missed appointments or cancellations that are made without 24 hours prior notice will result in a $20 missed visit fee for sick visits, $40 for Physical Exams and Saturday appointments, and $50 for imaging visits. No further appointments will be made until the fee is paid. Please call 770.322.9660 if you need to cancel or reschedule an appointment.
Consent for Treatment
The undersigned hereby consents to examination and treatment of the patient by Hillandale Primary Care physician(s) and to the performance of any diagnostic procedure, which is deemed necessary.
Authorization to Release Information
I hereby authorize the release of medical information, including pharmacy history, for the purpose of my medical treatment at Hillandale Primary Care.
I understand that I am responsible for payment in full at the time services are rendered, and it is my responsibility to know my benefits prior to my office visit. If insurance benefits are denied, applied to my deductible, or coinsurance; I am responsible for the balance due. The balance that is deemed patient responsibility must be paid before my next office visit, one month from the date of service in question, upon receipt of the E.O.B. (explanation of benefits) from your insurance company, or upon receipt of the first bill from Hillandale Primary Care (whichever occurs first). Thereafter, the balance will accrue a monthly late fee of $20. After 90 days all balances will be forwarded to an outside collections agency.