CANCELLATIONS, LATE PATIENTS, AND NO SHOWS:
Our goal at Century Health Care NP is to maximize the time your provider spends with you and minimize your wait time. In order to do so, we have a standardized policy for no-shows, cancellations, and late arrivals;
•CANCELLATIONS: We require 24-hour notice of cancellation for any appointments.
• LATE: You will be considered late if you arrive 15 minutes after scheduled appointment time. The provider reserves the right to reschedule visit to another date and time.
• NO-SHOW: If you do not arrive for a scheduled appointment and do not provide the office notice within at least 24 hours you will be considered a “No-Show”.
− Cancellation/No-show #1- Documented
− Cancellation/No-show #2- $35.00 charge will be incurred and charged to credit card on file or invoiced if no credit card on file*
− Cancellation/No-show #3-Discharged from office, per Provider’s review/request and/or $35.00 charge*
*All fees must be paid before a new appointment can be scheduled. Cancellations outside the required 24-hour notification window.
Please contact your preferred pharmacy to request medication refills. Once the request has been received, refills will be completed within 2-3 business days.
FINANCIAL RESPONSIBILITY: It is your responsibility to ensure that all services rendered by Century Health Care NP on your behalf are paid in full.
You hereby agree to accept financial responsibility for all charges incurred in the course of my treatment. In the case of Medicare or other insurance that the providers have executed an agreement with, you understand that you are responsible for paying any deductibles or co- payments required under the terms of your insurance plan. Depending on your insurance coverage at the time of your visit to the clinic, you may be asked to make a deposit on your account prior to seeing a provider.
Deposits will be applied toward charges incurred but may not represent payment in full for services. Should collection procedures become necessary, you agree to pay the collection agency’s cost and/or reasonable attorney’s fees. You hereby authorize the providers at Century
Health Care NP to bill Medicare and/or your health insurance plan. You hereby authorize the release of information acquired in the course of the examination and treatment, should it become necessary to secure payment of benefits.
It is important that you bring proof of insurance each time you visit the clinic. Please make every effort to let us know if your insurance carrier (primary or secondary insurance) or your personal information (home address, employer, and phone number) has changed since your last visit.
If patient determines they will sign up for one of the predetermined plans they are expected to set up automatic payment of monthly charges.
The patient will provide the front desk staff an active credit, debit, HSA, or FSA card. The information from this card will be entered into the applicable payment system and set up for recurrent payment. Century Health Care NP does not accept personal or business checks. Patients who have not signed up for recurrent monthly billing are expected to pay for services rendered at the time of service. Payment can be taken via cash or card through the Company’s electronic payment system. If the patient does not wish to sign up for a predetermined plan they will be charged for services rendered at the end of the appointment.
You agree that by signing below you consent and request that Century Health Care NP, its affiliates, and those acting on its/their behalf, may call or text you using an automated telephone dialing system and/or a prerecorded message. The types of calls or texts you may receive include those concerning the patient’s care, scheduling, reminders, prescriptions, advertisements or telemarketing messages concerning our benefits and services. Calls can be made to any number you provide or we obtain even if listed on a national or state Do Not Call registry. You understand that consent is not a condition of care.
By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or any other healthcare related function. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events. I consent to the receiving multiple messages per day from my healthcare provider, when necessary. I consent to allowing detailed messages being left on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me.
You may be required to come back for any and all lab results and may require an office visit and charge.
Patient will be required to sign this form upon their first initial visit at the provider’s office