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First Time Visit
Information for New Patients
After you have selected your physician and
you have scheduled an appointment we will make preparations for
your care. On your first visit please arrive 20 minutes
early to allow time for us to register you in our system,
prepare your medical record chart and obtain information on your
medical history. We will need the names/addresses of other doctors
who have treated you, unless you have already asked that your medical
records be transferred to us from your former physician. If insured,
you are required by your carrier to present your insurance card.
When you arrive at the Clinic, our receptionist will assist with
your registration. Your physician's nurse or medical coordinator
will let you know when the exam room is prepared for you.
In addition to diagnosis and treatment of
your medical condition, your doctor will generally schedule extra
time during your first visit to discuss your personal healthcare
goals and preventive health issues. If required, laboratory tests,
xrays or other medical services may also be performed in the Clinic
during your visit. Most diagnostic tests are available in the Clinic,
although you may be asked to return the following day if fasting
laboratory tests are ordered. Later, your physician or member of
our staff may call to check on your progress. However, please feel
free to call us any time you need assistance.
For your convenience, you can print and complete
these forms prior to your visit. Please give
them to the receptionist at the time of your appointment or
fax them to 512-930-4946.
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New
Patient Forms - Adult |
| Form
1 - Registration |
Form
1 - Registracion |
| Form
2
- Patient Consent |
Form
2 - Concentimiento Para Pacientes |
| Form
3
- Financial policy |
Form
3 - Polisa Financiera |
| Form
4 - Background
Health History-Adult |
Form
4 - Informacion Historial de Salud |
| Form
5 - Release Authorization (to 3rd Parties) |
Form
5 - Authorizacion Del Paciente Para Ejercer Permiso De Informacion Protejida De Salud A Grupos Terceros |
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Other
Patient Forms |
| Form
6 - Background
Ages 2 and under |
Form
6 - Departamento de Radiolojia |
| Form
7 - Background
Ages 2-16 |
Form
7 - Historial de Salud ninos de
2 anos o menores |
| Form
8 - ImmTrac Consent |
Form
8 - Historial de Salud ninos de
2 a 16 anos de edad |
| Form
9 - Release Authorization |
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| Form
10 - Radiological |
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| Form
11 - Bone Densitometry - DEXA Scan |
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| Form
12 - Stress Test |
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| Form
13 - Informed Consent |
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| Get
Adobe Acrobat Reader |
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Financial Policy
We appreciate payment at the time of service and
will accept personal checks, VISA, MasterCard, and Discover. Prompt
payment helps keep both our costs and fees down. After your medical
care is completed, you will receive a yellow (encounter) form and
be directed to our Cashier. There you will receive receipt of your
payment or insurance co-pay and any insurance forms that you may
need. Our Patient Accounts staff will electronically file most insurance
claims and periodically advise you of the progress of the claim.
Our Physicians share your concern about the cost of medical care.
We strongly believe that the best medical service is based on a
friendly, mutual understanding between doctor and patient. We therefore
invite you to discuss frankly with us any questions you may have
regarding our services or fees. If you anticipate problems with
your insurance coverage or personal payment, you are encouraged
to contact our financial counselor. The earlier we know about a
possible problem, the better we are able to develop suitable options
for you.
This is an agreement between Georgetown Medical
Clinic, as provider and creditor, and the Patient. By executing
this agreement, you, Patient, are agreeing to pay for all services
that are received.
Monthly Statement:
If you have a balance on your account, we will send you a monthly
statement. All balances are expected to be paid in full upon receipt
of this statement. Payments not received within 15 business days
of receipt of statement are considered past due and could be subject
to late fees or interest penalties.
Payment options if you have no insurance:
A. An advance deposit of $100 is required prior
to your first visit. You may pay by cash, check, or credit card.
Any remaining balance will either be refunded or credited towards
future services according to your wishes.
B. For extensive services such as deliveries, you may prefer to
secure a loan from your financial institution or credit union.
This can be discussed with our Financial Department.
Payment options if you have insurance:
A. You must pay all deductibles, co-pays, and
co-insurances in full at time of service. You may choose to pay
with cash, check, or credit card.
B. You may choose to pay for all services in full and file with
your insurance company.
Insurance: Insurance
is a contract between you and your insurance company. We are not
a party to this contract in some cases. We will bill your primary
insurance as a courtesy to you. Although we may estimate what your
insurance company may pay, it is the insurance company that makes
the final determination of your eligibility. You agree to pay any
portion of the charges not covered by insurance. If the insurance
does not pay within 60 days from the time services are rendered,
the balance may be billed to you.
Required Payments: Any co-payments
required by an insurance company must be paid at the time of service.
Because this is an insurance requirement, we cannot bill you for
these fees. If you fail to bring your copay with you to your visit,
a $5.00 processing/billing fee will be added to your account.
Discounts: Patients not covered by
insurance are eligible for a discount if payment is made in full
at time of service only.
Returned checks: There is a fee of $35.00 for checks returned
by the bank. If a returned check is received on your account, you
will be required to pay all fees associated with this check and
all future visits in cash prior to being seen.
Missed appointment fee:
When a patient does not show for an appointment, or cancels with
less than 24 hours notice, a $35.00 fee will be charged. When a
patient does not show for an extended appointment, such as a physical
or annual exam, or cancels with less than 24 hours notice, an $80.00
fee will be charged. This fee must be paid prior to scheduling a
new appointment. Patients with multiple missed appointments may
be asked to transfer their records to another practice.
Past due accounts: If your account becomes past due, we will
take necessary steps to collect this debt. If we have to refer your
collection balance to a lawyer, you agree to pay all lawyer’s
fees which we incur plus all court costs. In case of suit, you agree
the venue shall be in Williamson County, Texas.
Divorce: In case of divorce or separation,
the party responsible for the account prior to the divorce or separation
remains responsible for the account. After a divorce or separation,
the parent authorizing treatment for a child will be the parent
responsible for those subsequent charges. If the divorce decree
requires the other parent to pay all or part of the treatment costs,
it is the authorizing parent’s responsibility to collect from
the other parent.
Account summaries: If you require
an account summary for the most recent calendar year for flex plans,
income tax, court purposes, etc., you will be required to pay a
$10.00 fee for each account that you request this on.
Workers Compensation:
As of 1/1/03 we no longer perform services under workers compensation.
If you fail to state that your visit is for a job related injury,
you will be financially responsible for all charges incurred for
that visit.
Personal Injury:
We do not accept personal injury cases nor do we bill attorneys
for medical services. Any services performed in relation to a personal
injury case must be paid in full at time of service.
Disputes: Any disputes of your account
should be done in writing within 30 days of the receipt of your
statement. Your dispute will be addressed immediately and you will
be notified of the outcome within 30 days of the receipt of your
dispute.
Additional Services: Please be aware
that there are fees for additional services such as prescription
rewrites, copying medical records, depositions, and special forms.
Please check with the Financial Department for specific fees for
these additional services.
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News & Links
Densitometry and Osteoporosis
Georgetown Medical Clinic has upgraded
its diagnostic medical equipment with a Hologic Bone Densitometry
system (DEXA), as well as a Sahara Bone Sonometer, expanding our
ability to screen for and diagnosis osteoporosis.
"With the condition of osteoporosis, the inside of the bones
become porous, weakening them and making them more likely to break.
Osteoporosis is much more common in women than in men. This is because
women have less bone mass than men, tend to live longer and take
in less calcium, and need the female hormone estrogen to keep their
bones strong. If men live long enough, they are also at risk of
getting osteoporosis later in life. Once total bone mass has peaked--around
age 35--all adults start to lose it. In women, the rate of bone
loss speeds up after menopause, when estrogen levels fall.."
American Academy of Family Practice
Please ask your caregiver to assess your
risk factors for osteoporosis, it's quick and painless. Early diagnosis
and intervention can significantly decrease the potential adverse
effectsof this condition.
Community Impact
Read about Georgetown Medical Clinic in Community Impact. Click here: http://impactnews.com/georgetown-hutto-taylor/106-business-profiles/8293-georgetown-medical-clinic-georgetown.
Links of interest
The following links are provided below
for your use. As American Academy of Family Physicians members,
our doctors invite you to explore more information about personal
health at the AAFP website. However, please remember that website
healthcare information is continuously changing, and even if from
a reliable source, is no substitute for care by your regular family
physician.
AMERICAN
ACADEMY OF FAMILY PHYSICIANS
Austin
Avenue Professional Plaza
Georgetown Medical Clinic, along with several other area physicians,
is building a phase one, 90,000 sq. ft., office complex. The second
phase will be a similar building next to the first and will have
60,000 sq. ft., but no start date has yet been determined for the
second phase.
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