For your privacy, fields in red are disabled and will be completed when you arrive at Midwest Internal Medicine. Please ensure you have this information available when you arrive.
Patient Information Last Name First Name Middle Initial
Summer/Single Address Dates City State Zip Phone
Winter Address Dates City State Zip Phone
Date of Birth Sex Male Female Marital Status Single Married SS# - - Employer Work Phone
Responsible Person Self Spouse Parent Other If you chose other please explain relationship: Name Phone
Emergency Contact Name Relationship Phone
Referring Physician (who referred you here today) Name Phone
Insurance Is Medicare your primary insurance? Yes No Do you have an HMO? Yes No Primary Insurance Name Secondary Insurance Subscriber Name Relationship with Subscriber Subscriber's Date of Birth Subscriber's SS#
ALL PATIENTS: We bill insurance companies for your reimbursement as a courtesy for our patients. We will then wait 45 days for the insurance company to remit payment, if it is not paid within this time, you will need to contact your insurance company to expedite payment and make regular payments until such time as the claim is paid in full. In cases of financial hardship, please make arrangements with our billing office prior to seeing the doctor.
WE WILL NOT FILE INSURANCE CLAIMS UNLESS WE HAVE A COPY OF YOUR INSURANCE CARD WITH THE COMPLETE ADDRESS, PHONE NUMBER AND ID NUMBERS.
If you have insurance that we participate with we will file your claims for our reimbursement, if we have not received payment from the insurance company within 45 days it is then your responsibility to contact your insurance company to expedite payment. WE DO NOT FILE SUPPLEMENTAL CLAIMS UNLESS IT IS AN INSURANCE COMPANY THAT WE PARTICIPATE WITH.
AGREEMENT FOR PAYMENT AND RECORDS RELEASE
I acknowledge full financial responsibility for medical services rendered and I agree to pay in full at time of service or to make prior arrangements for payment. I acknowledge that it is my responsibility to verify that all prior authorizations have been obtained prior to all scheduled doctors appointments and procedures as required by my insurance plan.
If my account is placed for collection, I acknowledge responsibility for associated collection expenses (a 25% collection fee will be added to my balance turned over to the collection agency). Once your account has been turned over to collections you will no longer be seen at our office until the debt is satisfied. There will be a $20.00 charge for all returned checks.
I authorize you to release my medical records to my family doctor and / or the doctor who referred me, and to release any information requested by my insurance company necessary for processing the claim. I also authorize the insurance company to make payment directly to Midwest Internal Medicine. I also authorize you to request a copy or summary of my medical records from other care providers.
I agree to the payment conditions outlined above, and I understand that any overpayment will be refunded to me.
Signature__________________________________________ Date_________________________________
Conditions for Filing Insurance and Payment Responsibility
MEDICARE PATIENTS: Midwest accepts Medicare assignment, Medicare pays 80% of the allowable charge, you are responsible for the deductible and co-insurance amounts. Medicare has a $131.00 deductible every year starting January 1st. The co-insurance amount is 20% of the Medicare allowable. MEDICARE DOES NOT PAY FOR ROUTINE CARE OR SCREENING TESTS. YOU WILL BE RESPONSIBLE FOR NON-COVERED SERVICES.
We file supplemental insurance claims for the Medicare patients as a courtesy, we will file one claim with your supplement and wait 60 days for payment. At that time the claim will be pulled and the patient will be expected to pay the balance. In cases of financial hardship, arrangements can be made for regular monthly payments. Any follow-up with the insurance companies is the responsibility of the patient.
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. Other primary insurance companies, HMO's or automobile policies. (Section 1128B of the Social Security Act and 31 U. S. C. 3801-3812 provides penalties for withholding this information.) Regulations pertaining to Medicare assignment of benefits also apply.
SIGNATURE:_________________________________ DATE:____________________________
