New Patient Registration Form

Financial Policy

This is an agreement between Badia Hand to Shoulder Center, as creditor, and the Patient/Debtor named on this form.

By executing this agreement, you are agreeing to pay for all services that are received. Payment is expected at the time services are rendered. We accept cash, personal check, money order, cashier’s check, Visa and Master Card. We collect copay, coinsurance and any deductible at the time services are rendered.

Insurance: Insurance is a contract between you and your insurance company. We will file insurance claims only for plans with whom we have a contract with. We participate in some managed care plans. In order to file your claims, we require a legible copy of the front & back of the insurance card, photo ID, social security number and verification of benefits by your insurance company prior to visits. It is the responsibility of the insured/patient to supply current and accurate information for claims submissions. All copay, coinsurance and deductibles are due at the time services are rendered.

If you are covered by a plan that we are not participating providers for, payment is expected when services are rendered. We will provide you with an itemized receipt for you to file with your insurance. Your insurance company will be responsible for reimbursing you for any coverage you may have.

Collection fee: A fee totaling 30% of the balance due will be added to your account if we have to send your account to a collection agency. You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account to any credit reporting agency such as a credit bureau.

Waiver of confidentiality: You understand that if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Returned checks: There is a fee currently of $25.00 for any checks returned by the bank. Payment made on a returned check must be made in cash or by a money order.

Copying of records: You will need to request in writing, and pay a reasonable copying fee ($1/page for the first 25 pages and 25 cents for every page thereafter) if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history. Copies of images (x-ray, MRI) are available in CD and are subject to a $10.00 fee per disc.

Consent to photograph: I authorize Badia Hand to Shoulder, LLC and its affiliates to take pictures of my (or my child’s) medical or surgical procedure(s) and condition(s) and to the use of such pictures for treatment, scientific, educational or research purposes.

Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

My signature below certifies that I have read (or the form has been read to me) and I understand the contents on this form.

Acknowledgement of Privacy Practices

Patient Consent for use and disclosure of Protected Health Information

Further, I understand that I am entering into a contractual relationship with Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care, and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agrees not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician.

Furthermore, should a meritorious medical malpractice cause or cause of action be initiated or pursued, I and/or my representative agree to use American Board of Medical Specialties (“ABMS”) board-certified expert medical witness(es) in the same specialty as Physician. Furthermore, I agree that these witnesses will be members in good standing of, and adhere to the guidelines and/or code of conduct, defined for expert witnesses by the ASSH and AAOS.

In further consideration for this, Physician agrees to the same stipulations.

Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.

Credit Card Authorization

Successful treatment depends not only on the skill of your physician, but on the commitment, attendance and efforts of you, the patient, as well. At Badia Hand to Shoulder Center we pride ourselves on working with our patients in a timely manner so that the treatment process has the most minimal impact on our patients’ precious time. In addition, your timely attendance is important to facilitating short wait times and optimal patient flow.

The staff at Badia Hand to Shoulder Center is committed to accommodating your scheduling needs. In return, Badia Hand to Shoulder Center expects 24 hours’ notice prior to rescheduling or canceling an appointment. Any appointments cancelled or rescheduled without 24 hour notice will be assessed a $50.00 fee. This fee also applies to appointments in which a patient fails to attend or call. Our office has set this time aside to accommodate the schedule, and without proper notice, we are unable to provide the opportunity to another patient who may have requested the same time.

For workers compensation patients, should your workers compensation insurance refuse to pay this fee due to your negligence, you will be responsible for this fee.

I have read the cancellation policy and understand that I will be responsible to pay a cancellation/no show fee of $50.00 as indicated above. I authorize Badia Hand to Shoulder Center to charge a one-time fee of $50.00 to the credit card on file for each appointment missed. I understand that I will not be informed prior to this fee being charged to my account. I understand that if I give at least 24 hours advanced notice of cancelling an appointment, this fee will not be charged from my account. I understand that if I do not provide my credit card information to Badia Hand to Shoulder Center, I will still be responsible for this fee, and will be billed for this fee.