Office Appointment & No-Show Policies:
No Show or Late Cancellation:
[We request at least 24-hour notice to cancel or reschedule an appointment. Please call us during office hours to cancel or reschedule. Not informing/Late-cancellation/Leaving messages on answering machine are considered as “No Show” and you will be charged $50.00 fee. This fee is not paid by your insurance company. You are responsible to pay it. After three “no-shows” in a calendar year, we have the right to dismiss you from our practice.
Walk-in appointments are for URGENT medical matters only. Appointments are required for non-urgent matters]
I have read & agree with the above office appointments policies.
Advance Beneficiary Notice (ABN) & Agreement:
I hereby authorize IDEAL MEDICAL CARE OF NEW YORK, PLLC., the physicians (including covering physicians) and other medical staff to provide such medical care and treatment, including immunizations, as deemed necessary or advisable at each encounter. I acknowledge that no assurances have been made concerning the results from any services that I will receive from IDEAL MEDICAL CARE OF NEW YORK, PLLC.
I authorize payment directly to IDEAL MEDICAL CARE OF NEW YORK, PLLC. for the services. I understand that I am financially responsible for all charges not covered by the insurance including services, supplies and co-payments/deductibles. I am responsible to know how my plan works and I acknowledge responsibility for any payment denied due to seeing a provider out of network or due to incomplete or inaccurate information provided.
Advance Beneficiary Notice (ABN): (Physician/PA at Ideal Medical Care of New York, PLLC. may sometimes offer/deliver services/procedures/tests that he/she may determine to be ‘reasonable and necessary’ based on the information available. If, under Medicare or other insurance’s standards your diagnosis does not support these services/procedures/tests, Medicare/other insurance will deny coverage. In such cases the billing will be forwarded to you and you will be responsible for the cost of these services, not the physician or the company). In such a case I agree to be personally and fully responsible for the payment.
Tele-Health/Virtual Care:
(It means VIDEO & PHONE APPOINTMENTS and PORTAL/TEXTING communications. IT GIVES EASE OF ACCESS BETWEEN THE PATIENT AND HIS OR HER PHYSICIAN. WHEN NEEDED YOU CAN GET MEDICAL HELP FROM THE COMFORT OF YOUR HOME. This can be initiated by the patient or by the provider)
I understand that Tele-health is not for life-threatening emergencies. In such cases, 911 should be called. I understand that INSURANCE eligibility/rules/policies/fee apply. I agree to be responsible for the cost of the fees associated with Virtual Visits that are not covered by insurance or third party payment, including copays and deductibles.
Acknowledgment of Receipt of Notice of Privacy Practices: (HIPAA)
(Notice of privacy practices explains how we may use / disclose your protected health information and what are your rights in this regard. It’s available in the waiting room and online @ https://idealmedicalcare.net/hipaa-notice-of-privacy-practices for your convenience)
I have reviewed this practice’s Notice of Privacy. I have been given the opportunity to ask questions in this regard to fully understand it.
Certification: I confirm that the above information has been read by me / above information has been explained to me on request, and that I fully understand all of the above. I certify that all the information given by me is complete and accurate to my knowledge. In case of minors / dependents, I certify that I am the legal guardian and grant permission to receive services offered by Ideal Medical Care of New York, PLLC.