SoFHA
Patient Forms

Patient Paperwork


Description:

The Johnson City Internal Medicine new patient paperwork


Code:

4.001

Issued:

09/07/2018

Revision:

1

Revised:

N/A

Patient Information




















Employer Information










Health History





Current Symptoms

Conditions

Family History
































































Health Habits

Adult Vaccinations






Last Treating Physician








Registration, Billing and Collection Payment Policy

We are participating with Medicare, Tennessee Medicaid, and most Managed Care plans in the area. We will file these claims for you. Patients are expected to pay any deductibles, coinsurance or copay amounts owed at the time of service.

If you are a Medicare patient and do not have a supplemental plan or a Medicare Advantage plan, you are responsible for payment of the annual deductible, co-insurance and non-covered services at the time of service.

Patients with a third party coverage with whom we do not contract are responsible for payment in full at the time of service. As a courtesy, we will file your charges with this third party payer upon receipt of payment in full. Otherwise, we will provide you with a completed third party payer claim form to use in filing your insurance.

Patients with a High Deductible Health Plan that have not met their annual deductible amount on the date of service will be asked to pay SoFHA’s estimate of the allowed charges at the time of service. You will be billed for any additional deductible amounts after the insurance processes the claim.

Patients without verifiable insurance will be responsible for payment of all services rendered at the time of service.

We accept cash, check, Visa, MasterCard, Discover, American Express and Care Credit. In an effort to simplify the payment process, we provide a convenient, highly secure Credit/Debit/HSA card and Bank ACH payment program. You will be asked to provide a card-on-file (card/ACH-based) assurance at the time of service. After the insurance claim has been filed (if applicable), we will send you an electronic bill of your final financial responsibility. Your card-on-file will be charged for your out-of-pocket responsibility after the notice period and an electronic receipt will be emailed to you.

Please realize, however, that:

  • Your insurance is a contract between you and your insurance company. We are not a party to that contract. You are responsible to know your insurance benefits and the portion you will be liable for.
  • Depending on the specifics of the agreement we have with your insurance company, any portion of our fees not covered may be the responsibility of the patient/guarantor.
  • Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Any service not covered is the responsibility of the patient/guarantor.

Regardless of insurance payment, the patient and/or guardian remains responsible for all financial obligations incurred at the time of service. We realize that some balances may not be able to be paid in full at time of service and we will be happy to assist you in making payment arrangements.

By signing this financial policy acknowledgement of the financial responsibility is accepted. This will remain in effect until revoked in writing.


Acknowledgement of Notice of Privacy Practices

If no, what other number (i.e. cell phone, private work number) may we try to reach you to leave a message?






Emergency Contact Number other than YOUR home phone number: (Please note, you are giving permission for this emergency contact to receive your personal health information if necessary.)




I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected health information, i.e. lab results or billing issues, you can either leave or discuss the information with the following individual(s):

















ACCESS YOUR MEDICAL INFORMATION ONLINE, 24/7 ANYWHERE, ANYTIME!




Appointment Policy

State of Franklin Healthcare strives to provide excellent, quality care to each and every patient in a timely manner. In an effort to provide care when you need it, we have updated our policies on missed or canceled appointments and patient discharges.

We try to be stewards of your time and ours. So, when at all possible, please notify us as soon as possible and at least 24 hours in advance when you are unable to keep your appointment. We will assist you in selecting another time better for you and will still be able to allow someone else to be seen.

In addition, we need time to greet you and complete registration for your appointment. Therefore, we ask that you always arrive at least 15 minutes prior to your appointment. Should you be running later than 15 minutes past your appointment time, we may consider this a "no show" but will make an effort to see you.

We realize things happen and you may miss an appointment. We do track missed appointments and will notify you if this happens. Your provider determines how often you need to be seen; so, to receive proper care, you need to keep or reschedule appointments within the time frame discussed at your visit.

We never want to say goodbye to a patient but sometimes circumstances cause us to determine our relationship isn't working the way it should. If you miss or "no show" an appointment three times, you are not receiving the frequency of care you need nor are we able to use that time for another patient in need. At that point, you may be asked to establish with another provider for your care.

We feel a good relationship consists of mutual respect. However, sometimes challenges arise that may cause us to discontinue the relationship. In addition to a trend of missed appointments, other issues that qualify for dismissal include failure to comply with a prescribed treatment plan, inappropriate/abusive behavior to providers, staff or other patients or failure to pay outstanding balances.

Please let us know if you have any questions related to our policies. We are always available to answer your questions and thank you for the privilege to participate in your care.


Signature

By typing your name and initials in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.