Greetings from Northeast Indiana Genetics,
It is our pleasure to welcome you to the office. In order to provide quality services in a timely manner for our customers, we have enclosed several forms that must be completed prior to your appointment time.
Please bring updated insurance information when you visit. Any co-payments that are determined by your insurance plan should be paid on the date of your visit. It is the responsibility of the individual to understand their insurance benefits and check into relevant stipulations specific to their plan. Please check with your primary care physician’s office to have the referral (or prior authorization) faxed to the office.
If you do not have insurance, payment arrangements can be made.However, we require an up-front payment of one-hundred dollars ($100.00) on the first visit. We do accept Visa, MasterCard, and Discover credit cards for your convenience.
Any cancellation should be made 24 hours before your appointment.Cancellations made less than 24 hours prior to an appointment or not showing for your appointment significantly decrease the opportunity to schedule a future visit and possibly may result in you being charged a fee.
It is our office policy to confirm appointments 24 to 48 hours in advance.If for any reason, you do not receive a call to confirm your appointment, please contact us to verify the scheduled time of your appointment. We would greatly appreciate updates on any changes of names, phone numbers, addresses or other relevant information.
Please arrive 15 minutes before your appointment time with the following pages completed.If you or a family member (whomever is the patient) is currently taking any medications please bring those medications in the original bottle. A detailed list of current medications, strength, and dosage is also sufficient. We hope this information is informative and helpful.
FYI- We are relocated near the intersection of I-69 & West Jefferson Blvd. Our address is 7230 Engle Road, Ste. 303, Ft. Wayne, IN 46804.
We look forward to meeting you!
NORTHEAST INDIANA GENETICS
PATIENT INFORMATION FORM (PLEASE PRINT)
Referred by: __________________________________
Family Physician: ______________________________
Patient’s Name: _______________________________
Patient’s Address: ______________________________
City:________________________ State: _________ County: ________________ Zip:_________________
DOB: _____/______/_____ Social Security #:________
Patient's Race: [ ]Asian [ ]White [ ]Black [ ]Hispanic [ ]American Indian [ ]Other____
Gender: [ ]Male [ ]Female
Biological mother’s name (and DOB) __________________________
Marital Status: [ ]Single [ ]Married [ ]Divorced [ ]Widowed
Home Phone#: _____________________ Emergency Phone #1: _________________________
Mobile Phone #: ______________________ Emergency Phone #2: _________________________
Employer’s Name: ____________________________
Employer’s Address: __________________________
Employer’s Phone #: __________________________
Patient’s current medications (strength & dosage) : __________________________________________________________________
Information ON RESPONSIBLE PARTY OR SPOUSE
Responsible Party’s Name: ______________________________________
Responsible Party’s Address: _____________________________________
City: _______________________ State: _________ County: ____________________ Zip: __________
Social Security #: ___________ DOB:___/___/___ Relationship:__________
Employer’s Name: _____________________________________________
Employer’s Address: ___________________________________________
Employer’s Phone #: ___________________________________________
Insurance Name :_______________________
Effective Date:____________ Group#:_________________
I understand and agree that I am ultimately responsible for the balance of my account for any professional services rendered. It is my responsibility to verify insurance coverage or other financial assistance prior to seeking such services. I am responsible for follow-up on any treatments and test results. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes.
_________________________________________________________________________________ Signature (Patient/Parent/Guardian) Date
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND INFORMATION
Patricia I. Bader, MD
Northeast Indiana Genetics
7230 Engle Road. Ste. 303
Fort Wayne, IN 46804
Phone: (260) 482-3886 Fax: (260) 482-1910
NAME OF PLACE RELEASING INFORMATION: Northeast Indiana Genetics
PATIENT’S FAMILY DOCTOR ___________________________________________
OTHER SPECIALISTS _____________________
PURPOSE OF DISCLOSURE: Medical information & Coordination of services / treatment
PATIENT'S NAME:______________ DOB: ______________
TELEPHONE #: ________________ SSN#: ___________________
CURRENT ADDRESS: __________________________________________
I authorize you to release/exchange the following information (written or verbal) from my medical records.
Emergency room records Laboratory reports
History and physical Nursing notes
Discharge summary Medication documentation
Consultation Physician orders
Surgery and pathology Rehab assessments
X-ray reports Other:
This release of information will allow Patricia I. Bader, MD, to obtain medical records from other physicians who have participated in your care, or the care of your child(ren), in order to accurately diagnose or treat you and/or your child(ren) or make referrals of same.
This release of information will enable you to have access to your amniocentesis or other test results, when applicable, in a confidential and legal manner. It is the responsibility of the individual and responsibility parties to: understand their insurance coverage, limitations, and corresponding balances.
Any other party that may have access to the patient’s information:
This signed authorization is valid for 120 days or may be amended at any time.
Patient's or Parent/Guardian Signature:
Patient’s or Parent/Guardian Name (Printed):____________________________________________ Date: _____
Relationship to Patient:___________________________________________________________
Northeast Indiana Genetic Counseling Center, Inc.
7230 Engle Road. Ste. 140
Fort Wayne, IN 46804
Telephone: (260) 482-3886 Fax: (260) 482-1910
Thank you for selecting our practice for your healthcare needs. In order to prevent any misunderstanding regarding our payment policy, we request that you read and sign this explanation of our policy.
The patient (or family, if the patient is a minor child) is responsible for payment of his/her account at the time services are rendered. All co-payments are due at time of service, without exception.
We do realize that in some cases, healthcare can be unexpected and costly. In those exceptional situations, our business office manager is ready to discuss acceptable financial arrangements with you, prior to leaving the office. In the event of special testing or any non-covered (or covered) services, payment arrangements should be made in advance of having these services performed. I understand and agree that there will be a late fee added to my account if I fail to pay within thirty days from my first statement. The late fee charge will be twenty-four dollars ($24.00). I understand that I am solely responsible for this late fee and that it will not be billed to my insurance.
In the case of an auto accident or workman’s compensation claims, the patient is responsible for payment of the medical expenses incurred. As a courtesy, at the request of the patient, the appropriate insurance carrier will be billed; however, if the insurance company does not make payment, payment becomes the responsibility of the patient and/or responsible party. This is our policy and the update to you at this date of service that you choose and attended.
In the case of requesting additional documentation, twenty dollars ($20.00) will be charged for the first ten single-sided pages. An additional charge of twenty-five cents per page will apply for requests beyond ten pages.
In the occurrence of a court presence (deposition or related legal situation), a fee of three hundred ninety nine dollars ($399.00) will be charged per hour with a minimum of a four-hour time segment scheduled. Payment is to be received prior to the scheduled date.
Northeast Indiana Genetic Counseling Center submits insurance claims to many insurance carriers as a courtesy to our patients. If your health insurance carrier is not one of the companies with which we file claims, you will be provided with the necessary documentation that can be filed with your insurance carrier. However, it is the patient’s responsibility to resolve any problems that delay or prevent payment of the claims. Delayed processing and/or payment by your insurance company is not a valid reason for delayed payment for previously provided services. I hereby authorize the release of pertinent medical information to my insurance carriers. Furthermore, it is the responsibility of the individual to check on any insurance coverage(s) stipulations specific to their plan. We are not participating with several Medicaid programs and therefore will not bill or accept assignment from Medicaid. We do accept assignment for eligible Medicare patients and the patient is not responsible for any portion not covered by Medicare or a secondary insurance carrier.
Patients covered under an insurance plan cannot be seen without current Insurance, Medicare or Medicaid card, which must be presented to the receptionist at the time of service. You are responsible to promptly update us on any changes.
Referral to our professional collection service will be made for accounts with outstanding balances when the patient has not made firm credit arrangements with our business office for payment. Patients sent to our professional collection service will also be required to pay the collection/attorney fees incurred during this process and be placed on a “cash only” basis. If this policy is not followed, services will be discontinued with Northeast Indiana Genetic Counseling Center. I understand and agree that if I fail to keep my scheduled appointment and if I do not give at least a 24-hour notice of cancellation I will be charged thirty-two dollars ($32.00) for the scheduled time.
I have read and understand the above-described policy.
Patient/Responsible Party/Responsible Facility Date
Office Staff Witness: ________________________
ACKNOWLEDGEMENT OF COVERED & NON-COVERED SERVICES PATIENT'S FINANCIAL RESPONSIBILTY
I,_____________ , acknowledge that if my insurance has termed and will not cover these services and I am fully responsible for payment. It is the responsibility of the individual and responsibility parties to: understand their insurance coverage, limitations, and corresponding balances. I understand that failure to pay my balance or arrange for regular payments and follow that payment agreement may result in my account being turned to a collection agency. I agree that I will be responsible to pay for all collection fees in the event my account balance is turned to a collection agency after 90 days due to nonpayment. This is our policy and the update to you.
Witness/Title: ___________________ Information was presented on this policy
PRIVACY PRACTICES ACKNOWLEDGEMENT
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
Name: _____________________ Birthdate:____________
Patient's/Parent's/Guardian's Signature: _______________________________