I hereby assign all rights, title, and interest of my primary and secondary insurance to Philip Malinas M.D. & Associates for the treatment of my medical services.
Payment methods include cash, check and credit card. Payment plans can be arranged in advance.
Insurance Reimbursement: In the event you receive reimbursement from your insurance company for services rendered by Philip Malinas M.D. & Associates, that payment is due and payable to our office and should be immediately forwarded to us.
Insurance Deductible: Deductibles or co-pay’s are to be paid in full prior to services being rendered.
If you do not have insurance payment is due in full at the time of service.
Fee for returned checks: The fee for returned checks is $30. The fee may be added to your account and payment is required in full by cash or credit card.
Records requests: All records requests will need to be on a signed form. These records are available to the patient with a charge of .60 cents per page and require a minimum of 3 business days to be processed.
I authorize treatment of the patient named above and agree to pay all fees and charges promptly upon presentation thereof, unless credit arrangements are agreed upon in writing. In the event legal action should become necessary to collect on an unpaid balance due for psychiatric services rendered I agree to pay reasonable attorneys fees or other such costs as the court determines to be proper. If covered by an HMO, I understand that I cannot be seen until the required authorization has been obtained. I also agree to pay all expenses that are not authorized or covered by my HMO. It is agreed that payments will not be delayed or withheld because of any insurance coverage issues or pending claims, and that all proceeds of insurance are assigned to this office where applicable. A copy of this assignment is as valid as the original.
To cancel or reschedule an appointment you must call our office and speak to someone or leave a message a MINIMUM of 24 hours before your scheduled appointment time.
Patients that miss an appointment with out giving the required notice will be charged a fee ranging from $100 to $200 depending on the length of the appointment; this must be paid before a new appointment is scheduled, medications refilled, or medical records are released. TWO missed new patient appointments will result in not being accepted as a patient in our practice. Three missed appointments with our office as an established patient may result in the patient being discharged from our practice.
Medicaid will not allow for a no show or late fee to be applied to the patients account. These patients will be FILL IN ONLY and must call daily to get back on our schedule. They WILL NOT be scheduled for their next appointment.
I understand that Philip Malinas M.D. & Associates will agree to the restrictions requested. I understand that I may revoke this authorization in writing, except to the extent the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.
I further understand that Philip Malinas M.D. & Associates reserves the right to change their notice. Should the organization choose to change their notice, a current notice will be available, and I may request a current copy at any time.
To request any restriction, it must be submitted in writing to the office manager.
I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax and/or email. I fully understand the terms of this consent. Please accept or deny these terms below.
Strict Compliance to this agreement is REQUIRED
Over the last 2 weeks, how often have you been bothered by any of the following problems?
This information may include personal, psychological, medical, social, educational, clinical and/or professional information regarding the patient above.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.