Procedure Description: for school, sports, well-woman, employment, DOT, and preventive medicine
What To Expect: You
will have a thorough history and review of your medical problems, a
complete examination and laboratory evaluation that is age, sex, and
situation appropriate.
Preprocedure: Come fasting (water and meds only on am of appt.)
Postprocedure: You
should know all results from our evaluation that are still pending at
the time you leave the office within one week's time. If not, we ask
that you call...don't presume your results are normal, presume we have
slipped up and not called you!
Likewise, you should hear from us
regarding any agreed upon referrals to specialists, procedures, or
tests within 2 business days after leaving the office. If you haven't,
please call.
NEW PATIENT INFORMATION Sheet
BAXTER CLINIC OF HERNANDO, PLLC 124 West Commerce Street Hernando, MS 38632 phone (662) 429-5221 fax (662) 429-7917 www.BaxterClinic.yourmd.com
****************************************************** This (printer-formatted) form is needed for all new patients. Please print this out and complete it prior to your first visit, then bring this form and your insurance card when you come to the office.
If your insurance requires a designated primary care provider, please make sure that we are listed as such with your insurance company prior to arrival. Otherwise, we may either be unable to see you, or you would possibly be responsible personally for your entire bill.
****************************************************** PATIENT INFORMATION ****************************************************** YOUR NAME
Occupation__________________ Work Phone_________________
****************************************************** EMERGENCY / ALTERNATE CONTACT PERSON OF CHOICE ******************************************************
Name _____________________________________________________
Pager__________________ Work Phone ____________________
Home Address _____________________________________________________
****************************************************** INSURANCE INFORMATION ****************************************************** Please
be sure that all of the following information is complete. We will
gladly submit claims to your insurance carrier for you, but we can only
do this if we have all of the following information.
PRIMARY Insurance Company name________________________________
I have completed this form fully and completely, and certify that I am the patient or duly authorized general agent of the patient authorized to furnish the information requested. I agree that if my insurance requires a copayment for office visits, I will pay this at the time of the visit. I understand that even though I may have insurance coverage, I am responsible for payment of services. I request that payment of authorized benefits be made on my behalf from Medicare, Medicaid, or any other insurance carrier to Baxter Clinic of Hernando, PLLC for any services furnished to me. I authorize release of medical information relative to these services for medical records and insurance claims purposes. Baxter Clinic of Hernando, PLLC is also authorized to seek third party reimbursement for these services rendered to me if appropriate.
I understand that overdue charges may be turned over to an agent for collection of these charges as well as additional collection fees, court costs, and / or attorney’s fees. This is a lifetime authorization unless revoked by me in writing.
_____________________________________________________ Signature of patient, parent, or responsible party and Date
After Hours Help / Contact Information
The same office number serves for after hours help: 662-429-5221.
When you call, you will reach the automated system, which will allow you to select 1 of 4 prompts. Your choices will be:
(1) This one is for doctors, hospitals, ER's, home health nurses, or pharmacies only. Please do not select this one.
(2)
PRESCRIPTION REFILL REQUESTS. This choice will allow you to leave your
detailed information on: who you are and what you need refilled (with
name of drug, quantity, and how it is prescribed). Please also give the
pharmacy name and phone number where you want the prescription called
in. The staff will address these requests the following business day.
(3)
NON-URGENT PROBLEMS TO ADDRESS. This choice will allow you to leave a
message for the nursing staff or providers to address the following
business day. Of course, if you are reading this, you could also just
email us!
4. URGENT PROBLEMS TO ADDRESS. This choice will
allow you to leave a message regarding your problem. The answering
system then pages the "on-call" provider. Unless Dr. Meacham is out of
town, he always takes this call himself. He calls back and gets your
information, then gives you a call as soon as he can. This is usually
within 30 minutes of the time you call, and should never be more than
one hour from the time you call.
If you feel you need to be seen after hours, you can either:
(a) discuss this with Dr. Meacham following the instructions above, or
(b) go to the ER or after-hours clinic of your choice.
Please
never wait by the phone to make a decision if you think that you must
be seen immediately, or if you are having an emergency. Remember to
trust your instincts. It is always better, safer, and more prudent to
GO! and be seen, than to not go and regret it.
Please note that
for both your protection and ours, the policy exists regarding narcotic
prescriptions or narcotic prescription refills:
We DO NOT CALL IN NARCOTIC PRESCRIPTIONS AFTER HOURS OR ON THE WEEKENDS.
If
you are on a narcotic prescription chronically, it is your
responsibility to make sure that you do not run out of medication
during one of these times.
"Self Pay" Patient Info
Dear Patients:
Due to the difficulty we are having collecting money owed to us after the time of an office visit, we are regrettably forced to begin the following policy effective October 15, 2001:
AT THE TIME OF CHECK-IN - All "Self Pay" patients will be required to deposit $50 in cash or by check to be seen in the clinic. New patients will be required to deposit $100. - Alternatively, the receptionist can hold a valid credit card to charge against at the time of check-out. - This is an average charge for a patient's office visit. If your charge is less, you will receive a refund at the time of checkout. - NO EXCEPTIONS will be made to this requirement. If you cannot pay, you will not be seen.
AT THE TIME OF CHECK-OUT - Any remaining balance from charges incurred will be due either by cash, check, or credit card. - Alternatively, if the balance is large because of an extensive evaluation or laboratory testing, then a payment plan may be arranged with our billing department.
DISCOUNTS - A 20% discount will be given for all services rendered if payment is made in full at the time of service. - Alternatively, if a payment plan is arranged and you are 100% on-time with payments, you will be given the discount back upon completion of payment in full. - If you do not pay in full at the time of service, or if you are not on-time with your payment plan, then 100% of the balance will be due.
FOR PERSONS WITH BALANCES OWED AT THIS TIME
Now: Payment is due in full prior to being seen again in the office. Alternatively, if the amount owed is greater than $100.00, at least one-half must be paid on your account, and a new formal arrangement for payment completion must be arranged at the time of check-out, to include the new day's charges as well.
Next visit: If you have not been on-time with your arranged payment plan, payment is due in full prior to you being seen again in the office.
We appreciate your business. We strive to provide you with cost-effective high quality care. We also try to provide medication samples whenever possible since you do not have the help of an insurance prescription benefit. I do not like having to begin this policy, but our experience with this matter has shown us that we have little other choice.
I believe that the policy I have created is reasonable and fair. I also believe that my discount policy is generous, considering that no hospital and most doctor's offices offer no type of discount at all. If you have any questions, please do not hesitate to ask.
Sincerely, Rob Meacham, MD
ANY PATIENT THAT IS MEDICALLY UNSTABLE OR IN EMERGENT NEED OF MEDICAL CARE WILL BE SEEN WITHOUT REGARD TO PAYMENT STATUS AT THE TIME OF CHECK- IN.
Now Open Saturday Mornings!
Beginning December 8, 2001, we will begin opening on Saturday Mornings!
We
will begin seeing patients at 8:30 am. Check-in and Lab draws only will
begin at 8:00 am. The last chance to sign in for the morning session
will be at 11:30 am.
At least initially, there will only be one
person in the front, one nurse, and one provider. This means that the
total number of patients that we will be able to see will limited.
Therefore, the "cut-off" time may actually be earlier than 11:30 am.
The provider and staff present will vary depending on the date.
As
the Saturday morning practice builds, we expect to add additional
services and providers. We are happy to be able to provide this
additional service for your convenience!
Medicare Waivers
Medicare
Waivers are what we ask all Medicare patients to sign prior to
performing any additional testing or procedures above and beyond just a
regular office visit. Medicare's definition of "reasonable and
necessary" and therefore what they will approve and cover are
unfortunately not always in concurrence with current national
recommendations for "standard of care".
A classic example of
this would be a mammogram. The current recommendation by the American
Cancer Society and others is for yearly mammograms over the age of 50.
However, Medicare will only pay for a mammogram every TWO years. If one
is done the next year, Medicare will deny payment, saying that it is
"not reasonable and necessary". Another prime example would be
cholesterol monitoring when on cholesterol-lowering drugs. The
manufacturer's recomendations are to monitor liver function and
cholesterol levels every 6 months while on the medication. Medicare
will only pay for a full cholesterol profile once a year.
We
practice medicine by following the national standards and prudent
norms, not Medicare standards (which are less). Therefore, we
often-times seek to do more than what Medicare will likely approve.
The Medicare Waiver allows us a legal means of being able to collect our usual fees for these services or procedures.
The following text is what appears on our Medicare Waiver that we present to you in the office:
*******************
"Medicare
will only pay for services that it determines to be "reasonable and
necessary" under section 1862(a) (1) of the Medicare Law. If Medicare
determines that a particular service, although it would otherwise be
covered, is "not reasonable and necessary" under the Medicare program,
Medicare will deny payment for that service. In my professional
judgement, these services are needed in your particular case. However,
I believe that, in your case, Medicare is likely to deny payment for
one or more of the following reasons:
- This lab test for this condition - This service (Pap smears, chest xrays, EKG's as part of routine physicals, etc.) - This injection or this many injections for this illness or prevention (vaccines, etc.) - This many visits, treatments, or services during this period of time - Like services by more than one physician during the same period - More than one office visit per day - This procedure
PATIENT AGREEMENT Should
any of these determinations be made by Medicare Part B, I agree that I
have been informed prior to the service(s) being rendered, and I agree
to be personally and fully responsible for the payment of the
service(s) checked below."
********************
(What
follows on the office paper form is a complete list of all services
with their appropriate Medicare CPT code, and written description, and
our charge.)
If you have any questions about this waiver or our expectation that you sign it when necessary, please do not hesitate to ask.
