WESTOVER HILLS PRIMARY CARE
New Patient Registration Packet

By signing this form you acknowledge receipt of the Notice of Privacy Practices of Westover Hills Primary Care on the date indicated. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change.

Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Please read this payment policy and ask us any questions you may have. A copy will be provided upon request.

Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility.

Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company.

Non-covered services. Some services may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

No Show / Late Cancellation Fees. We charge $50 for missed appointments and for appointments not cancelled with at least 48 hours notice. These charges will be your responsibility and billed directly to you.

Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Claims submission. We will submit your claims and assist you in any way we reasonably can. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.

Coverage changes. If your insurance changes, please notify us before your next visit. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. If a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice.

I hereby give my consent for Westover Hills Primary Care to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). The Notice of Privacy Practices provided describes such uses and disclosures more completely.

I have the right to review the Notice of Privacy Practices prior to signing this consent. The practice reserves the right to revise its Notice of Privacy Practices at any time.

With this consent, the practice may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and calls pertaining to my clinical care, including laboratory test results.

With this consent, the practice may mail or e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

By signing this form, I am consenting to allow the practice to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.