Patient Information (Page 4 of 4) in pdf

Alicia W. Grossmann, MD PA is committed to providing comprehensive, high quality medical care and to work with you, the patient, to achieve

the highest level of personal health possible. THANK YOU for giving us the opportunity to serve you & your family in your healthcare needs.

INSURANCE FILING is done on your behalf as a service to you and requires the presentation of your current insurance card & drivers’ license at

each visit. It is vital that you notify us ASAP of any changes (Insurance, job, address, phone, etc) or you may be required to pay in full and file

your insurance yourself. Remember that it is your responsibility to provide us with your correct insurance information, correct address and correct

phone contact information before your visit. If your account is overdue or sent to collections, you will incur an additional fee.

AFTER HOURS: "On Call" For Urgent medical problems - Call the main line (512) 568-3565 and choose option 1. Please have your pharmacy

number & your current medications & doses on hand. When you call after hours, we will respond promptly. If you do not receive a response

within 60 minutes, please call back and verify your phone number. Make sure your phone line does not block caller ID restricted lines, or the

doctor will not be able to return your call. You will be assessed a $25 fee for after hours calls. Routine refills are not handled after hours.

R E F I L L S of regular medicines take 24-72 hours to process. Do not wait until your prescription runs out because you may be charged $25 rush

fee. Contact your pharmacy to begin the refill process at least 2-3 days before running out of medication. Even if your prescription says 0 refills,

the pharmacy will submit a refill request to Alicia W. Grossmann, MD PA. Please note that you must keep follow-up appointments or your meds

will not be refilled. Any prescriptions for controlled substances (triplicate prescriptions) will need 48-72 hours’ notice and must be picked up.

REFERRALS are a labor-intensive process. Your cooperation is appreciated. •You need to be seen by Alicia W. Grossmann, MD PA to obtain a

referral. •Contact your insurance to find out who accepts your insurance and please notify us if you have a specific specialist you prefer. •Once the

physician orders the referral, our referral coordinator will contact your insurance carrier to obtain authorization. Response times from insurance

plans varies and can be anywhere from 1-7 business days. Do NOT go to a specialist without an approval. You may be turned away or billed personally

for services. HELPFUL HINTS for referrals: Not all insurance plans require a referral. Contact your insurance if you are unsure. Please call the

office at least one week in advance for referral changes or extension requests.

MEDICAL RECORDS: Your medical records are maintained and protected by privacy regulations. You may request a copy of your medical

records at any time. Dominion/Dr. Warfield will occasionally be taking call for Dr. Grossmann and can access medical records for this purpose.

LABWORK AND RESULTS: When a physician orders lab work for you, if you come in and have it drawn within one week you will NOT be

charged an additional co-pay. Once the blood is drawn, the specimen will be sent to a lab to be tested. Once received, a physician will review

the results. Please note that HIV and STD results must be picked up in our office and can not be given out over the phone. Within 1 week of

having your labs drawn you will receive a phone call with the results. If it has been more than 1 week after a lab draw and you have not gotten

the results, then please contact the office.

BILLS FROM LABS: You should call the lab to make sure they have your correct insurance information and to find out why they are billing you.

It may be that you are responsible for a deductible. Occasionally, a test may not be covered by your insurance and the lab will bill you.

PRESCRIPTIONS FOR CONTROLLED SUBSTANCES: You may be subject to intermittent drug testing for any long-term prescriptions of

controlled substances (for example: some anxiety, ADD, and pain medications).

WE SCHEDULE APPOINTMENTS: based on type and number of problems in an attempt to keep our schedule on time. When scheduling, we

ask you to list ALL the problems that you would like to have the doctor address. You are asked to call us back should anything else come up so

that we can adjust the appointment or reschedule if necessary.

WORK-INS: We discourage walk-in appointments, please call ahead. As a work-in, your visit may be associated with a wait to see the doctor.

Due to schedule constraints, we cannot guarantee which provider you will see. As a work-in, the provider will address one acute issue. Issues

such as routine care, refills or follow-ups will not be addressed on a work-in basis.

PLEASE CANCEL: If a situation arises where you cannot make your appointment, please notify our office 24 hours before your appointment or

you will be charged a “no show” fee. If you arrive more than 15 minutes late to your appointment, please note that you may be asked to

reschedule and you may be assessed a “no show” fee of $25.

WORKER'S COMP AND DISABILITY: We will not be able to see you for these issues. Please contact your employer for further instructions.

PRE-OPERATIVE EXAMS: Please bring your surgeon’s information, any records pertaining to the surgery and the surgeon’s orders with you.

TB TESTS: Once you receive a TB test, you will need to return to have the test read within 48-72 hours. TB Tests are not given on Thursdays.

_______________________________

____________________

(Signature of Patient)

(Date)

Page 4 of 4

Patient Information Page 4

Related Articles

Related forms

Related Categories