Practice Policies

In applying to be a patient of Meyer & Malin Family Practice, I agree to the following practice policies:

1 ) Relationship: I understand that applying to be a new patient does not mean that I will be accepted as a patient, and that NO DOCTOR PATIENT RELATIONSHIP EXISTS until I have been seen by one of the doctors for an initial appointment, my medical history has been reviewed, and the Doctor agrees to accept me as a patient. I understand that if I have not been forthcoming with my medical history, that I can be dismissed from the practice.

2 ) Payment for Services: I understand that it is my responsibility to keep my insurance information up to date so that the Practice can bill my insurance for my care in a timely manner. In the event that I do not do this, I understand that I am responsible for any charges for my care. If I am paying for my care out-of-pocket, I understand that payment is due at the time of my visit.

All co-payments and fees for service are due at the time of your appointment.  We accept Visa, Master Card or Cash for services.  We will accept checks from patients who are already established with our practice; however, we do not accept checks for new patient appointments.

3 ) Missed Appointments: Missed appointments are a costly matter for any physicians office. Due to recent increases in patient cancellations or no shows, our practice has implemented a fee to cover the cost. Any patient who fails to cancel their scheduled appointment, without 24 hours prior notice, or fails to show up for any scheduled appointment, will incur a $25.00 charge for the first missed appointment, and a $50.00 charge for the second missed appointment. You may be dismissed from our practice for the third missed appointment. THIS FEE IS NOT COVERED BY YOUR INSURANCE COMPANY. You will be expected to pay the fee before you can be seen again.

4 ) Assignment Of Insurance Benefits: I hereby authorize direct payment of medical/surgical benefits to Meyer, Malin and Associates, PLLC for services rendered by the doctors in person or under their supervision. I understand that I am financially responsible for any balance not covered by my insurance.

5 ) Authorization To Release Information: I hereby authorize Drs. Meyer/ Malin to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits.

6 ) Medicare – Medicaid: I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.

7 ) HIPAA Privacy Statement: This office is required by law to maintain the privacy of, and provide individuals with, a notice of our legal duties and privacy practices with respect to protected health information. A copy of the HIPAA Privacy Policy Statement of Meyer, Malin and Associates, PLLC is available for your review and if you would like you may have a copy for your records.

8 ) Prescriptions of Controlled Medications: We reserve the right to randomly drug test any patients who are receiving narcotic medications from our doctors. Patients found to be positive for illegal drugs, or patients on chronic pain medications who test negative for their prescribed medications may be dismissed from our practice.   Patients who are on narcotic pain medications are subject to being randomly selected for a count of their narcotic medications.

My Fieldset
  1. (required)
  2. (valid email required)
 

cforms contact form by delicious:days

%d bloggers like this: