New Patient Registration Form

• I acknowledge that Diamond Headache Clinic will use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record.
• Additional explicit authorization for release of information may be required for disclosing medical information to third parties that are not affiliated with Diamond Headache Clinic.
• I have access to the Diamond Headache Clinic Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about now the practice may use and disclose my confidential information.
• I understand that the practice has reserved the right to change the Notice of Privacy Practices. I also understand that a current copy of the Notice of Privacy Practices is available upon request.
• I understand that this consent is valid until it is revoked by me. I may revoke this consent at any time with written notice of intent mailed to the practice. I may not be able to revoke consent in cases where the practice has already used or disclosed my health information.

The following information is to familiarize you with our billing policies:

• Diamond Headache Clinic will bill your out of network insurance company for your initial office visit only. Any co- pays and/or deductibles will be due at the time of service. We DO NOT bill insurance companies for follow-up visits unless we are contracted with them or you have Medicare. Although eligibility has been checked with your insurance company prior to your office visit, this is NOT a guarantee of payment. Benefits are determined by your insurance company once the claim has been received and reviewed.
• We don’t accept HMO, WORKERS'I WORKMAN'S COMPENSATION, MEDICAID, or any forms of public aid.
• If your insurance company was billed and payment is not received within 45 days, the balance will be transferred to the patient's responsibility. This office cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. Any portion of the bill not paid, or denied, by the insurance carrier, will be the patient's responsibility.
• If you have Medicare and a supplemental or secondary insurance carrier, please call Medicare and advise them of your secondary or supplemental information for the coordination of benefits. Medicare will coordinate claims with your secondary insurance carrier.
• We DO NOT bill secondary insurance carriers unless Medicare is your secondary insurance or we are contracted with the secondary insurance carrier. Use the Explanation of Benefits (EOB) from your primary insurance carrier to bill your secondary insurance and attach any appropriate documentation (i.e., statement from the Diamond Headache Clinic).
• Upon receipt of payment from your insurance company, you will receive a statement showing your balance due. Payment is expected within fourteen (14) days. For your convenience, we accept Visa, MasterCard, Discover, and American Express. You can also apply for Care Credit which offers interest-free, low monthly payments if you qualify. Please contact this office for information.
• If payment, IN FULL, is not received, you may be charged a $15 re-billing fee each time we issue you a statement on an outstanding balance over 30 days.
• If your bill is not paid and is transferred to our professional collection agency, then your information, which may include, but is not limited to, your name, address, phone number, social security number, employment and employment phone number, will be provided to them. You will be charged an additional 25% of your outstanding balance as well as any related court costs and attorney fees.
• If your insurance company requests a claim form, fill out your portion of the form and attach a copy of your itemized statement provided by our office. A physician's signature is not required. It is not necessary for our office to fill out the "Attending Physicians" portion of the claim. The statement is authentication in itself.
• You are advised that this office charges at least a $50 fee per form for any forms completed on a patient's behalf. This includes, but is not limited to disability forms, Family Medical Leave forms, Attending Physicians forms, itemization of charges etc.
• Please be aware if you request medical records this service will be processed by a third medical records vendor upon completion of your release of information form.
• You must inform our office if you have a new insurance carrier or if the insurance carrier has a new claim address. Please send us a copy of the front and back of your new insurance card so we can update our records. Failure to do so may result in delayed claims and/or responsibility for unpaid claims.
• The Physician Assistants at the Diamond Headache Clinic are expert clinicians who have advanced degrees and are board-certified. They are trained to diagnose and treat a variety of medical conditions, and prescribe medication under Physician's supervision. We would like to advise you that calls or electronic correspondence sent to the Physician Assistants or nurses for issues that normally would necessitate an office visit (such as requesting advice or medication changes) will be charged between $50 and $150 per call, depending on length of call. Emergency situations cannot be communicated electronically to the provider; we kindly ask that you go to the nearest emergency room.
• If you are unable to attend your scheduled appointment, please notify the office at least 24 hours in advance. Failure to do so will result in a cancellation fee of $75 for new patient appointments and $35 for established patient appointments.

Please note: This office reserves the right to change its fees at any time without prior notice