Patient Registration Form

//Patient Registration Form
Patient Registration Form 2018-03-12T00:52:04+00:00
  • Patient Information

  • Required for billing
  • Workers Compensation Insurance Information

    *** All information is required ***
  • Health Insurance Information

    *** All information is required ***
  • PRIMARY INSURANCE

  • Required for billing
  • Secondary Insurance

  • Required for billing
  • Attorney Insurance Information

    *** All information is required ***
  • Disclosures and Consents

  • ASSIGNMENT OF INSURANCE BENEFITS:

    I hereby authorize direct payment of my insurance benefits to Terren D. Klein MD, PA for the services rendered to me or my dependents by the physician or under his supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Terren D. Klein MD, PA is unable to collect from my insurance carrier for whatever reason.

    MEDICARE/MEDICAID/CHAMPUS/TRICARE INSURANCE BENEFITS:

    I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct the payment of my or my dependent’s authorized benefits to be made directly to Terren D. Klein MD, PA on my behalf.

    AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:

    I hereby authorized Terren D. Klein MD, PA to release any of my or my dependent’s medical or incidental non-public personal information that may be necessary for medical evaluations, treatment, and consultation or the processing of insurance benefits.

    AUTHORIZATION TO MAIL, PHONE CALL OR E-MAIL:

    I hereby authorize Terren D. Klein MD, PA representative to mail, call or e-mail with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, claims, insurance benefits and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying Terren D. Klein MD, PA to that effect in writing.

    AUTHORIZATION TO REQUEST LAB/X-RAY/MRI/EMG OR OTHER DIAGNOSTIC RESULTS:

    I hereby authorize Terren D. Klein MD, PA to request my or my dependent’s lab, x-ray, MRI, EMG or other diagnostic results that may be necessary for medical evaluations, treatment, and consultation or for the processing of claims.

    CONSENT TO TREATMENT:

    I hereby consent to and authorize the performance of all treatments, surgeries, testing and medical services deemed advisable by the physician and staff of Terren D. Klein MD, PA to me or to my dependent of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I fully understand this agreement and consent will continue until cancelled by me in writing.

  • ______________________________________________
    Signature of Patient/Responsible Party

    ______________________________________________
    Print Name of Patient/Responsible Party

  • ______________________________________________
    Date

    ______________________________________________
    Relationship to Patient

  • Agreement of Financial Responsibility

  • We are committed to providing quality care and service to all our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

    • Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards and pre-approved insurance for which we are contracted providers. There will be a $30 service charge on all returned checks.
    • It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy and any pre-authorization requirements of your insurance company.
    • We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
    • If we have a contract with your insurance company we bill your insurance company first, less any co-payment(s) or deductible(s) and then bill you for any amount determined to be your responsibility.
    • Please understand some insurance coverage have Out-of-Network benefits that have co-insurance charges, higher co-payments, higher deductibles and limited annual benefits. If you receive services that are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In-Network rate.
    • Proof of payment and photo ID are required or all patients. We will ask to make a copy of your ID and insurance care for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.
    • Workers Compensation and Attorney Case patients we will attempt to verify information for your workers compensation claim and attorney cases prior to treatment. It is your responsibility to update us of any insurance changes, multiple workers compensation injury claims, and disputes to your case, attorney changes or any other financial changes to your claim or case.
    • Attorney Cases must provide $300 AND an L.O.P. (letter of protection) from your attorney for the first appointment. All follow-ups are covered by the L.O.P. for the date of injury and body parts specified in the L.O.P. until you are discharged by our physician.
    • We will bill all workers compensation bills to the workers compensation insurance for payment. If your claim was closed or denied in its entirety you will be financially responsible. You must provide your new insurance information or you will be expected to pay for all services rendered at the end of your visit.
    • We will bill all attorney cases to your attorney for payment. You or your attorney will be expected to pay in full for all services rendered once your case has settled or closed.
    • No Show Policy: If you fail to show up to your appointment you will be asked to pay a “NO-SHOW” fee of $25 which will be due prior or on your next appointment date. This does not include any other fees due for services rendered i.e. any co-payment(s) or deductible(s) and any amount determined to be your responsibility. We will waive the no-show-fee if you call us to cancel or reschedule your appointment at least 24 hours ahead of time.

    I have read the financial policies contained above and my signature below serves as acknowledgement of a clear understanding of my financial. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.

  • ______________________________________________
    Signature of Patient/Responsible Party

    ______________________________________________
    Print Name of Patient/Responsible Party

  • ______________________________________________
    Date

    ______________________________________________
    Relationship to Patient