Dear Patient,
Welcome to our office. We appreciate the opportunity
of being of service to you. Our office is dedicated to excellence in patient care. To
maintain our high standards, we believe that it is important that we communicate our
policies to you.
Please take a moment to read and become familiar with these policies. Should you have any questions, the office staff would be happy to help you. By presenting these policies in advance, we can avoid any surprises or misunderstandings. We appreciate your time and your understanding.
Are You a Member of an IPA or HMO Plan?
Please be advised that our office has no longer any agreement with any HMO or IPA plan. Patients covered under these plans will be required to pay directly for the service that they receive.
Who Does the Billing?
All insurance and patient billing and collection related efforts would be done by PhyCon Enterprises, an independent billing agency. All inquiries should be addressed to PhyCon Enterprises at 8635 West 3rd street #1170, Los Angeles, CA 90048. Telephone # 310-659-8927 or 800-932-1002.
Copying Policy
There is no charge for copying up to ten pages. However, I understand that there is a minimum charge of $ 10 for copying my medical records. Copying will be at 25 cents per page after the minimum fee. I agree to pay this fee, should I need copies of my medical records for any use. Alternatively, I may request a professional medical photocopy service to obtain copies of my chart at my own cost. If my file is in storage, I agree to pay a minimum of $25 for its retrieval.
Cancellation Policy
Please call our office within 24 hours of a scheduled appointment if you need to change or cancel it. For Monday morning appointments, our office should be notified no later than Friday noontime. This will allow other patients in need of care to be accommodated. We retain the right to apply a $35 charge for recurrent no show or late-cancellation patients who have made follow up appointments.
Release of Medical Information
I hereby authorize any prior or present treating physician, hospital or other health institution, to release all of medical information, by any means of communication, to Dr. Farshid Sam Rahbar.
Fee for Report Preparation
A fee for preparation of any special of report will be applied based on physician’s hourly rate. Examples of these reports include school reports, immigration reports, reports for airlines, reports for life or health insurance, disability or medical-legal reports, reports for social security disability, etc. Compensation is not to be expected from health insurance carriers. Payment is due at the time of service.
Payment Policy
I hereby assign payment directly to Dr. Farshid Sam Rahbar for all benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all the charges whether or not they are paid by insurance. I hereby authorize the doctor to release any information necessary to secure the payment of benefits. A copy of this agreement is deemed as valid as the original. I also understand that it is my responsibility to make sure that the bill is paid in a reasonable time. If for any reason any portion of the bill is not paid by my insurance within thirty days from the date of service, I further agree to make arrangements for prompt payment.If my policy prohibits direct payment to the doctor, then I hereby instruct and direct my insurance carrier to make out the check to me and mail it directly to Dr. Rahbar’s medical office.
I agree to pay for my medical service, insurance deductible or co-payments or any unpaid prior balance at the time of the service and I hereby agree to pay such due amounts in one of the following manners:
Please circle the method that you are planning to pay:
· By check or cash.
· By authorizing Dr. Farshid Sam Rahbar to charge my payment/credit card as follows:
[ ] Each visit only [ ] For Balance Due After My
Insurance Pays
· Cardholder Name: _______________________________________________
· Credit Card Number: ____________________________________________
· Expiration Date: _________________________________________________
· Name of Credit Card: _____________________________________________
My signature below also constitutes authorization to charge my credit card. I understand that I can cancel this credit card authorization through a written notice to the doctor. I that case, I agree to pay for any balance due by cash or check as explained above. A finance charge may be applied by the billing/collection agency for due amounts not paid within thirty days.
| _____________________________ | __________________________ | __________ |
| Patient Name | Patient Signature | Date |
As a courtesy to our patients, we bill your insurance. However, this office can not accept responsibility for collecting payments or negotiating settlements on disputed claims. Patients are expected to pay toward their service at the time of visit.
