New Patient Packet

1. Individual’s financial responsibility

Our practice participates in most insurance plans. However, since each plan has different requirements, coverage limitations and exclusions, it is the responsibility of the patient to understand and meet the requirements of their individual plan.

• Payment is due at the time services are rendered. The practice accepts cash, check, debit and/or credit card payment.
• I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered services.
• Co-payments are due at time of service.
• If my health plan determines a service to be “not payable,” I will be responsible for the complete charge and agree to pay the costs of all services provided.
• If uninsured, I agree to pay for medical services at the time of service or speak with TMPG’s financial department about self-pay payment-plan options.
• A $25 fee applies to a check returned for insufficient funds.

Health insurance plans may not cover all costs. Charges for which the patient is responsible are due when services are rendered.

Copay

A portion of the charge not covered by insurance and due from the patient, collected at each office visit. A preventive annual physical may be exempt.

Deductible

The amount you must pay each year before the health plan starts paying for covered services. With a high deductible and no significant medical expenses, the entire office visit may need to be paid out of pocket because office charges are often lower than the deductible.

Coinsurance

The percentage of maximum allowable charges you must pay after meeting the deductible. It may vary by service.

Out-of-pocket maximum

The maximum amount you are responsible for per calendar year. Once reached, the plan pays covered medical expenses at 100%, with no further copay, deductible, or coinsurance payments.

Maximum allowable charges / contractual discount

Participating providers accept negotiated prices for covered services. Even when a deductible applies, charges cannot exceed the insurer’s maximum allowable charge. The difference between cash prices and negotiated prices is the contractual discount.

Non-covered services

Your health-plan contract may exclude certain services. Insurers may specify exclusions, and coverage varies significantly by plan.

If your account balance exceeds $50, the outstanding balance must be paid by cash or credit card before further services are provided.

2. Insurance authorization for assignment of benefits

I authorize and direct payment of my medical benefits to The Medical Partners Group on my behalf for services furnished by its providers, including Dr. Rohan Gupta. I am responsible for knowing the nature and scope of my coverage. A TMPG provider may not participate in my particular insurance company or plan, and some or all services provided at a given time may not be covered. I remain responsible for payment of those items and services.

3. Authorization to release records

I authorize The Medical Partners Group and its providers to release to my insurer, governmental agencies, or another entity financially responsible for my care all information, including diagnoses and records of treatment or examination, needed to substantiate payment for medical services or required for precertification, authorization, or referral to other medical providers.

4. Medicare request for payment

I request payment of authorized Medicare benefits to me or on my behalf for services furnished by The Medical Partners Group and its providers. I authorize any holder of medical or other information about me to release to Medicare and its agents information needed to determine these benefits or benefits for related services.

5. Cancellation, missed and no show fees

Office appointments cancelled with less than 48 business hours’ notice are subject to a thirty-five-dollar ($35.00) cancellation fee.

Cancellations. We know that your time is valuable and that there may be special unavoidable circumstances that cause you to cancel. In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly at 559-221-7500 to cancel your appointment. When we schedule your appointment we are reserving time for your particular needs, so we kindly ask that if you must change or cancel an appointment you notify us no less than 48 hours (2 business days) beforehand.

Missed and no show appointments. We understand that occasional missed appointments can occur for a variety of reasons. A no show or late cancellation is defined as missing an appointment without cancelling 48 hours (2 business days) before your scheduled time. The practice may discharge a patient for multiple missed appointments.

6. Medical records request

Upon request, we will provide you with copies of medical records, subject to the charges provided under Health & Safety Code section 123100. Those charges are subject to annual adjustment based on statute. The per page fee will not exceed one dollar ($1.00) per page.

7. Forms completion policy

Completing paperwork for schools, employers, Family Medical Leave Act (FMLA) claims, long-term care, life insurance, the Department of Motor Vehicles, and disability claims goes beyond your routine medical care and therefore cannot be billed to your insurance company. Since all forms require your physician’s signature, we are personally responsible for the accuracy of the information provided. Incomplete or inaccurate information may have far-reaching consequences for your case, so filling out forms requires careful consideration and a considerable amount of our time.

It is our office policy to charge a processing fee of $25 per form. We will complete the form and fax it to the designated recipient, or return it to you if you prefer, within 5 to 7 business days of receipt of payment. This charge does not apply to social security disability, Medi-Cal, or patients who receive SSI/SSP benefits.

8. Prescription refills

New patients should contact their previous physician for an adequate medication supply until establishing care. The office policy is to process established-patient refill requests within two business days, although exceptions may or may not be granted. Request refills at least one week before running out, or two weeks for mail order. Refill requests can be made through the patient portal if you have access to it, or by calling the office at 559-221-7500. You may also ask your pharmacy to send the request on your behalf.

Many medications, including diuretics, blood-pressure and cholesterol-lowering medications, anti-seizure medicines, sleep aids, painkillers, and stimulants, require periodic blood work and/or an office visit for safe and effective use. Refills cannot be processed without recent required results or visits. Patients not seen within the past 12 months must have an appointment to renew medications.

Financial responsibility acknowledgment

By signing below, the undersigned acknowledges that: (i) I have been provided a copy of The Medical Partners Group Patient Financial Responsibility Form; (ii) I have read, understand, and agree to its provisions and specified terms; (iii) I agree to pay all charges due or becoming due for the patient’s care, including co-payments and deductibles required by an applicable insurance plan; (iv) third-party benefits will be credited to the patient account; (v) regardless of insurance status or coverage, I am ultimately responsible for the balance for services rendered; (vi) if I fail to make a required payment in a timely manner, I am responsible for all costs of collecting the money owed; and (vii) failure to pay when due may result in late-payment charges.

I further agree that a photocopy of this Patient Responsibility Financial Statement is as valid as the original. Once signed, I agree to all terms and conditions contained herein and the agreement is in full force and effect.

HIPAA regulations

The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, primarily enables workers to carry healthcare insurance between jobs, prohibits discrimination against beneficiaries with pre-existing health conditions, and guarantees coverage renewability for multi-employer health insurance plans.

The HIPAA Privacy Rule establishes national standards protecting medical records and other individually identifiable health information, collectively defined as protected health information. It applies to health plans, healthcare clearinghouses, and providers conducting certain transactions electronically. The Rule requires appropriate safeguards, sets limits and conditions on uses and disclosures made without authorization, and gives individuals rights over their protected health information, including rights to examine and obtain a copy of their records, to direct a covered entity to transmit an electronic copy to a third party, and to request corrections.

HIPAA’s key objectives:

• Protect your health information.
• Make processing health claims and other transactions easier and less costly.
• Create consistent national security standards for protecting the rights of patients and consumers.

At The Medical Partners Group we feel that the privacy and confidentiality of your health information deserve priority, and we take it very seriously. We will not discuss or release your health information with anyone without your consent, unless required by law. You may review the summary of the HIPAA Privacy Rule at hhs.gov.