New Patients - Preventive Medicine Associates, PLLC

New Patients

Patient Forms

Please download and complete these forms before your first visit to our office.

New Patients

Preventive Medicine Associates is accepting new patients. Please fill out the form below and someone from our office will contact you shortly.

Patient Name*:
Address*:
Email Address*:
Phone Numbers:



Primary Insurance*:
ID number*:
Secondary Insurance:
Secondary IDnumber:

Requested Physician:
Will other members of your family also be new patients? Please enter their names and birth dates.

Current Doctor*:
Reason for leaving:
Date of your last complete physical*:

Comments:

(*) Fields Are Mandatory

Office and Financial Policies

Arriving for your Appointment

New patients should plan on arriving 30 minutes before your scheduled appointment. You will need to provide and verify demographic and insurance information. Valid state identification is also required. These tasks need to be completed before your appointment to ensure you are seen on time. Arriving late for your appointment affects every patient seen by our provider after your appointment. Therefore, arriving late may have a delay in being seen or will be rescheduled.

No Show and Cancellation Policy

New patients who cancel their appointment without 24 hour notice or do not show will have a $125 fee for physicals and $75 fee for office calls assessed. Our office needs at least this amount of time to fill your time slot with another patient who needs that valued time with their provider. This fee will need to be paid before your next appointment can be scheduled. We understand there may be extenuating circumstances. Please call the office as soon as possible. Be advised that multiple no shows may lead to dismissal from the practice.

Forms

A fee of $15 per form is due when brought in or sent to the office for completion outside a scheduled appointment. Your form will not be completed until payment is made. Allow 10 business days for completion.

Patient Compliancy

The practice reserves the right to discontinue the physician/patient relationship due to patient non­ compliance regarding medical and/or office policies. This includes, but not limited to, excessive no shows, not returning phone calls to the practice for appointments or continued rescheduling of such appointments. Please note that once a patient is discharged from the practice, our office policy reads we do not reinstate a patient back into the practice.

As a reminder, our patients are expected to be seen at regular intervals, especially when on maintenance medications. These intervals will be determined by your primary provider.

Patient disrespect to staff or providers is not tolerated and will result in the discontinuation of the physician/patient relationship.

Financial Policy

It is the patient’s responsibility to ensure that we participate with their insurance carrier prior an appointment. Since each insurance carrier has multiple plans that can vary with employer group contracts,we cannot always tell you in advance whether your charges will be covered. Any remaining balance is the patient’s responsibility.

Self-Pay Patients

Self-pay patients are required to set up payment arrangements with the Billing Dept. staff prior to your appointment.

Statements

You will receive a statement for any balance due after your insurance carrier pays. If 60 days have lapsed without payment, a $50.00 administrative fee will be added and your account will be referred to our Collection Agency. If you have not contacted our Billing Department within 60 days of being referred to our collection agency, you will be discharged from the practice. Please note that once a patient is discharged from the practice, our office policy reads we do not reinstate a patient back into the practice.

In consideration of financial hardship situations, we require contact with our Billing Department to establish a payment plan within 30 days. You will be given a contract to sign explaining our payment plan options.