Billing Information

Current Medications - must select one

Allergies

Please list any medications you are allergic to and the reaction that you have had - must select one

Surgical History

Please list all surgeries you have had and an approximate date they occurred (must select one)

Review of Symptoms

Please mark any of the following symptoms that you have currently havet

Medical History

Please mark any of the following conditions that you have currently or have had in the past

Family History

Please check if applies

Did your Mother have any of the following?

Social History

Please mark those which apply

Weight Loss History

Cancellation and No- Show Policy

When you schedule an appointment at Life Without Limits, you have our direct attention. When you do not keep your appointment, that time is lost. When you miss a visit, not only are you depriving yourself of necessary follow-up, but you are also preventing another patient from utilizing that office time.

For this reason, we are implementing the following cancellation and no-show policy:
PATIENTS MUST PROVIDE 24-HOURS NOTICE IF YOU ARE UNABLE TO MAKE A GIVEN APPOINTMENT. This will give the staff adequate time to offer your appointment time to another patient. If this policy is violated, a $50.00 charge will be applied to your account.

We do understand that your lives are busy and that unexpected events occur, therefore, some leniency will be offered at our discretion. If excessive cancellations and/or no shows occur, we do reserve the right to discharge you from our practice.

Our scheduling software enables us to send patients email or text to your mobile device the week before your appointment. We will not use your email address or phone number for any marketing or third-party purpose. Please, fill out the information below if you would like to take advantage of this reminder system.

Please, let us know if you have any further questions or concerns.

Consent to Provide Information

Please list the names of individuals that you give us permission to speak to regarding your health care.

Primary Care Physician Information

It is necessary to collect information from your family physician in order to bill your insurance company for any office visit.

It is essential we receive this information. If we do not receive this information, you may be charged for your office visit.

Patient Consent Form

The Department of Health and Human Services have established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also creased to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel need your health care information and information about treatment, payment, or health care operations, to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS

To our Valued Patients,
The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and providers continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in performing services to our patients.
It is our policy to properly determine appropriate uses of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent an inappropriate use of PHI.
We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the solution promptly.

Patient Financial Policy

We are committed to providing you with the best possible care and will help you receive your maximum allowable insurance benefits. However, we need your assistance and your understanding of our payment policy. Your insurance contract is between you, your employer, and the insurance company. (Not all services are covered by all contracts.) We participate and accept assignment from most major payers, which means covered charges, will be paid directly to us. If we do not participate in your insurance plan, you may still choose to be seen by the practice. However, any uncovered services will be paid for by you.
Your insurance policy is an agreement between you and your insurance company, not with your medical provider. As a courtesy to you, we will file a claim with your insurance carrier on your behalf. Any remaining balance will be billed to you once we have received payment from your insurance carrier. Additional fees which typically are not covered by insurance plans will be charged for services such as copying of medical records, completion of disability forms and our program fee.
Due to current federal and insurance regulations, all co-payments, co-insurance, and deductibles are collected at the time of service.
We accept cash or checks, and for your convenience, Visa, MasterCard or Discover.
A fee of $30.00 will be charged for checks returned for insufficient funds. An additional monthly fee will be charged on all past-due accounts and co-pays not paid at the time of visit.
**We do require that all appointments are confirmed. It is our policy to charge a fee a no-show fee of $50 for any appointment that is a no show by the patient, rescheduled or canceled completed 24 hours of the originally scheduled appointment. **
You may be asked about an account balance when you call and make an appointment or at check in to see one of our providers. Please be prepared to pay your co-pay and any prior balance at the time of the appointment or call to make payment arrangements ahead of time with our billing department.
We encourage you to contact us promptly for assistance in the management of your account. We are here to help you and will be happy to answer any questions you may have about your treatment or insurance coverage. In an effort to ease the financial burden, we are happy to make payment arrangements with you. Feel free to inquire about further instructions in obtaining an agreement that will allow you to make monthly payments by mail or credit card for a monthly fee.
We send e-statements only. We need a valid email address on file for your statement to be delivered to you. By signing below, you acknowledge that you understand that we do not send paper statements. These will be delivered by email only and you are responsible for updating your email address.
If you fail to make payments and your account remains delinquent, we will utilize our collection agency after 90 days. Our collection agency charges a 35% fee for collecting funds. This will be added to your account balance if you do not pay or make payment arrangements within 90 days of your first statement.