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. No-show and cancellation policy

Please provide at least 24 hours’ notice to cancel an appointment. Appointments cancelled with less than 24 hours’ notice and no-show appointments may incur a $35 fee, payable before the next visit. The practice may discharge a patient for multiple missed appointments.

6. Medical records request

Upon request, copies of medical records will be provided subject to charges allowed under Health & Safety Code section 123100, adjusted annually by statute. The source policy states a per-page fee not to exceed .25 cents per page.

7. Forms completion policy

Completing paperwork for schools, employers, FMLA claims, long-term care, life insurance, the DMV, and disability claims goes beyond routine medical care and cannot be billed to insurance. All forms require a provider’s signature, and the practice is responsible for the accuracy of the information. Incomplete or inaccurate information may have far-reaching consequences, so completion requires careful consideration and considerable time. The processing fee is $25 per form. A completed form will be faxed to the designated recipient or returned to you within five business days after payment is received.

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. Requests are handled most efficiently through the patient portal; alternatively, ask your pharmacy to send the request.

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 safeguards, limits uses and disclosures without authorization, and provides rights to examine and obtain records, direct electronic transmission to a third party, and request corrections.