Patient Contract
This contract is between the undersigned patient and healthcare providers
at Bagheri Medical Group. The purpose of this agreement is to ensure that
we can continue to provide timely, professional and efficient medical care
for all of our patients. Additionally, we hope that by adhering to these terms
we can ensure a pleasant work environment for our staff as well as a calm
and friendly environment where our patients will enjoy receiving healthcare
services for many years.
We make a commitment to provide the following services:
1) A member of our group or a designated covering physician will be
available for emergency coverage 24 hours a day.
2) We will make every effort to see you for urgent medical matters on
the same day you contact us. True emergencies will be referred to the
emergency room but we will make every effort to make sure you don’t have
to avoid this inconvenience if at all possible.
3) We will make every effort to obtain necessary lab tests, imaging
results and consults as soon as possible given your condition so we can
begin appropriate therapy for your condition.
4) We will make every effort to assist in expediting appropriate medical
insurance authorizations, pharmacy refills and durable medical equipments
and other administrative matters in order to address your health concerns.
5) We work hard to develop and maintain referral patterns in the local
medical community as well as in nearby major medical centers that will
provide our patients with the best available sub-specialty consultants and
access to care.
The patient by signing this contract agrees to the following:
1) To act courteously and respectfully with the staff as well as other
patients encountered in our office.
2) To be prompt for appointments and call as soon as possible to
change or break appointments. We allow a 15 minute grace period on two
occasions for patients who are late for their appointments but can not
guarantee service for patients later than 15 minutes on the day of their
appointment. This is essential in order for us to be able to provide prompt
care for patients who are on time.
3) To restrict phone calls for phone calls for appointments, radiology
reports and referral requests and all other non-urgent medical and
administrative issues to regular business on weekdays.
4) To pay penalties for cancellations recognizing that insurance
companies do not pay such penalties and these funds have to be dispensed
out of the patient’s personal funds according to the following schedule:
Cancellations within 24 hours and Missed appointments $50. Being more
than 30 minutes late for an appointment is considered a missed
appointment although we will make every effort to see you despite these
time constraints.
5) Pay all bills in full upon receipt. We will not make further
appointments for patients with bills outstanding for longer than 60 days.
We do not have the financial clout at this time to provide payment options,
deferred billing or discounts for services we provide.
6) To make sure you have all your prescriptions and appropriate refills
at the time of your appointments. We can no longer provide prescription
refills outside of office visits. We will charge a minimum of $25 or $5 per
prescription for refills outside of office visits starting 7/1/07. We do not
routinely change medications based on pharmacy requests or insurance
preferences even though this may save you or your insurance company
money. We are healthcare providers and not insurance agents. Our
knowledge of insurance finances is very limited and we will make no effort
to increase that knowledge. We are here to provide healthcare and not
perfect our paper pushing techniques. If you encounter such possible
savings in your pharmacy bills it is your responsibility to let us know you
would like a medication change.
7) We aim to provide optimal medical care to those who want to have
the best service and are genuinely interested in their health. Frequent
cancellations, no shows, being late for appointments or otherwise non-
compliance with the guidelines of the above agreement signifies to us a
lack of concern for our practice and/or for your own health related issues.
We reserve the right to refuse further services to those patients who
repeatedly display disregard for their own health.
8) We understand that issues with personal health can be stressful,
often disappointing and at times even frightening. We recognize the anxiety
that health issues can create and we have every intention of assisting our
patients in dealing with these emotions as well as obtaining the best
possible results in maintaining your health. However, we will maintain at any
cost a professional, friendly and non-toxic environment for all who work
and receive medical care in our office. We reserve the right to refuse
further services to those who repeatedly treat the staff with condescension,
disrespect or entitlement.
_______________________________
Patient name (please print)
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Patient signature and date