Follow Up Form- Rheumatology

ID
Appointment Date
Calendar Resource
Appointment Type
Appointment Time
Patient's Name
Vista Rheumatology Follow Up Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Date of Birth*
Email Address:*
example@example.com- To send you a copy of this form upon completion.
Age:*
Height:*
Weight*

HEALTHCARE FINANCIAL AGREEMENT
Thank you for choosing us as your medical clinic. Our team of skilled providers are committed to providing you with quality and affordable health care. For us to continue providing excellent care, we offer this agreement to all patients. A copy will be provided upon request. If you do not agree to the terms listed below, we will be unable to proceed with your appointment(s). The parties may not alter this Agreement.

1. Registration: To ensure accurate billing and the proper delivery of care, all patients must complete our patient information form. We also need a copy of your valid driver’s license and current valid insurance card. Most insurance companies have time limits for filing claims, so it’s important to provide us with accurate and up-to-date information. If your insurance information is incorrect or if you fail to notify us of any changes in a timely manner, you may be responsible for the balance of your claim.

2. Insurance: We accept assignment and participate with many insurance plans. If your insurance plan is not a plan we participate with, please reach out to your insurer for options or payment in full will be due at each visit. We encourage you to familiarize yourself with your insurance benefits and advise you to reach out to your insurer with any questions to ensure you receive the maximum coverage available.

3. Claims: We will submit claims to your Primary, Secondary, and Government Issued Tertiary insurance, and we will support you in any way we can to help get your claims processed correctly. However, it is your responsibility to ensure any additional information requested by your insurance company is provided in a timely manner. Please remember that your insurance benefits are a contract between you and your insurance company. Please also be aware that any amounts left as your responsibility is determined by your insurance company.

4. Patient copayment: All copayments are due at the time of service. This is part of your agreement with your insurance provider.

5. Uninsured patients: We understand that some patients may not have insurance, to accommodate this we offer a discount for those who pay at the time of service. If the charges are not paid at the time of service, the discount will no longer apply and the full charged rate will be expected before the next visit. If a balance remains, you will receive a monthly statement that is due upon receipt. Any account balance over 90 days will be subject to review for collection action.

6. Outstanding Balance: If your balance remains unpaid for more than 90 days, we may need to temporarily suspend services until the balance is settled. Please understand that if your account remains unpaid and is sent to a collection agency, each referral to collections or report to a credit bureau may negatively impact the responsible party’s credit score. You will also be responsible for any additional collection fees (such as interest, court costs, reasonable attorney’s fees, etc.), as outlined by law. We want to work with you to avoid this, partial payments or payment plans may be accepted with prior arrangement.

7. Missed appointments: If an appointment is missed, a fee may apply. If you need to cancel an appointment, please let us know at least 24 hours in advance so we can allow someone else the opportunity to receive care.

8. Credit Card: A credit card will not be kept on file unless opted into. I understand by not having a card on file, I will receive a statement, and payment will be due upon receipt. Failure to pay to upon receipt, may result in additional fees.
I opt in to have my credit card on file, which may be charged for missed appointments, copays, deductibles, outstanding balances, or other services.
Thank you for taking the time to review and agree to our Health Care Financial Agreement. If you have any questions or need further clarification, please don’t hesitate to reach out to our team. We’re here to help patient’s live life again!

By signing below, you acknowledge and bind the terms of the agreement.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date

HIPAA Release Form

Vista Healthcare
Authorization to release or use information for treatment, payment, or healthcare options

I hereby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by Southwest Spine and Pain/Vista Healthcare in order to carry out treatment, payment, or health care options. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing the consent form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.
In addition to the authorization for release of my Personal Health Information (PHI) described above, I acknowledge that I have the right to authorize access and disclosure of my Protected Health Information (PHI)-including medical records, billing, payment, appointments, and healthcare- to anyone of my choosing. Examples: spouse, partner, parent, adult child, caregiver, or other trusted individual. This information may be shared with the following individual(s):
This authorization will expire 12 months from the signature date. Written notice will be required to remove any individuals listed on this form.
Ok to send records from Southwest Spine and Pain Center/Vista Healthcare provider to external doctor involved in my care
Provider Name
By signing below, I attest that the information provided above is accurate and agree to the terms described above.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
PLEASE CLICK SUBMIT
Should be Empty:

	Yes	No	If yes, Date:	If yes, Details:
Surgery
Infection
Hospitalizations
Injury (including falls)

Vista Rheumatology Follow Up Form

Patient Information

Medical Information

Refill of Medications

HEALTHCARE FINANCIAL AGREEMENT

HIPAA Release Form

Authorization to release or use information for treatment, payment, or healthcare options