Dear Patient,
In order to serve you, our valued patient, in a more efficient
manner, please be advised of the following office policies:
1. Consultation requirements
As pulmonary specialists, it is very important that, along with
the enclosed history forms, you also bring along all pertinent information.
We ask that you bring to your appointment any chest
x-ray films and CT of the chest films that have been done
within the last 5 years.
Films may be obtained at the radiology group where the x-rays
were originally performed. PLEASE DO NOT RELY ON FILMS BEING
DELIVERED TO OUR OFFICE. To ensure a complete consultation,
please pick up the films and hand carry them in at the time of your
appointment.
If you have any questions or difficulty obtaining your films,
please give us a call prior to your appointment so that we can assist
you.
2. Refills on medications
Please have your pharmacy contact our office 3 to 5 days prior
to when your medications are expired or completed. Practice
good healthy habits and call us with your medication requirements
prior to completion of your prescription. This policy allows
you to take your medication without any interruptions or compromise
in your health and well being. Routine medication refills
require at least one yearly follow up exam with your physician.
PRESCRIPTION REFILLS ARE NOT PROCESSED ON SATURDAY OR SUNDAY.
Please allow 48 hours for all refills to be processed.
3. Laboratory/Diagnostic testing
All test results are reviewed by the ordering physician within
1 working day of receiving results. Patients will only be
notified of abnormal test results requiring treatment. Patients
are always encouraged to contact our office during normal office
hours (Monday through Friday, 9a.m. to 5 p.m.) to obtain verbal
results from our nurse.
4. Cancelled/missed appointments
A scheduled appointment means that time is reserved only for you.
If an appointment is missed or cancelled with less than a 24 hours
notice, Foothill Pulmonary reserves the right to bill the patient
according to the scheduled fee or according to the rules of the
patient's health plan.
5. Authorization/Eligibility
Because of the contractual relationship between Foothill Pulmonary
and all managed care insurance plans, I am aware that every visit
requires pre-authorization prior to any procedures or lab tests,
which may delay my medical care. Co-payments are expected
to be paid at the time of service and are required for each visit.
AUTHORIZATION FORMS MUST BE PRESENTED AT THE TIME OF SERVICE OR
YOU MAY BE REFUSED SERVICE OR BE RESPONSIBLE FOR THE BILL AT THE
TIME OF SERVICE. I understand I musts be seen prior to the
expiration date of the authorization, and must be eligible with
the insurance at the time of service will notify the office of any
change in my insurance, primary care physician, or demographical
information. Failure to do so might delay the billing process
and/or medical care.
6. Disability forms and other non-insurance forms
Due to the complexity of completing certain disability forms and
other non-insurance forms, effective January 1, 1998 our office
has instituted a charge of $25.00 per form to complete these forms.
As before, we will not charge for the usual handicap sticker and
electrical discount forms. If you have any questions about
this fee, please speak with one of the office staff.
7. Consent to treat
The examination you will be receiving is a very focused one, for
the express purpose of pulmonary diagnosis and treatment.
The doctor-patient relationship established by this examination/treatment
is limited to this specific purpose. We perform only the examination
and care necessary to address this current problem.
Because of this narrowly limited purpose, it is important that
we advise you that this examination does not replace your regular
medical evaluations done by your personal physician. If you have
any other questions or concerns about your health, you must discuss
these with your own doctor.
We provide this information because we would like you to be able
to plan for your entire health care needs and not inappropriately
rely on a limited purpose visit as if it were a comprehensive examination
of your overall health.
Your on going partnership and working relationship with our office
and staff allows us to better meet your medical needs. We
appreciate, very much, your cooperation and adherence to our policies.
We understand the need for personalized medical care and we
strive to meet your needs.
To print this document and fill out
the consent form, click icon below
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