NewPatient 2010RegistrationUpdated
NewPatient 2010RegistrationUpdated
NewPatient 2010RegistrationUpdated
, FACC
Patient Registration
Account Information
SSN#__________________________ Id#______________________________
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Heart of the Valley Patient Registration Form
PAYMENT POLICY:
Balances are due within receipt of statement. There will be a $35 charge for all returned checks. Patients with HMO's and
PPO's of which we contract, will only be responsible for co-pay amounts and deductibles provided all pre-authorizations
have been obtained. It is the responsibility of the patient to maintain and verify eligibility with all state funded or private
insurance companies. HMO and PPO patients will be held financially responsible for all charges incurred which are not pre-
authorized. ______________ Initials
A $100.00 fee for ALL patients will be charged for missed appointments not cancelled within (24) twenty-
four hours prior to the scheduled appointment.
PLEASE NOTE: WE DO COURTESY CALLS 24 HRS PRIOR TO YOUR APPOINTMENT, HOWEVER IT IS NOT OUR
RESPONSIBILITY TO REMIND YOU!! ___________Initials
Holter Monitors given out to patients must be returned within (72) seventy-two hours of receipt. Holter
Monitors given out on a Friday must be returned the following Tuesday. Otherwise a $25.00 fee will be
added per day late. ______________ Initials
I understand that I must submit a current and valid insurance card in order to have the insurance company billed directly. I understand
that if I fail to submit a valid and current insurance card or if I fail to provide a valid secondary insurance card I will be billed at the non-
contracted rate for services payable within 45 days. I understand that I will be held financially responsible for any and all unpaid balance
exceeding 45 days. I understand that any insurance disputes will be settled between the insurance company and myself and any unpaid
balance will be due and payable to Andrew J. Maxwell M.D INC upon receipt. _________________Initials
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Heart of the Valley Patient Registration Form
on the consent. My "protected health information" means health information, including my demographic
information, collected from me and received by my physician, another health care provider, a health plan, my employer
or a health care clearinghouse. I also understand that postcards addressed to me may be mailed as follow-up reminders.
I also understand that I may choose to receive "Electronic Protected Health Information" (ePHI) via an alternate form of
communication via email if I provide an email address. I understand I have a right to review the doctor's Notice of Privacy
Practices prior to signing this document. The doctor has the right to change the privacy practices without notice. I may
obtain a revised notice by calling the office and requesting a copy be sent in the mail or by asking for one at the time of my
next appointment.
_________________________________________ ________________________________________________
(Signature of patient or parent if minor) ( Date)
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Heart of the Valley Patient Registration Form