OK
Personal info
Demographics
Additional information
Consent
First name
*
Last name
Personal Email
*
Age
Phone
*
What is the patient's gender?
What is the patient's preferred language?
What is the patient's emergency contact information?
What is the patient's ethnicity?
What is the patient's insurance?
*
What are the patient's symptoms?
What are the patient's medications?
Please list all medical conditions
Please list all past surgeries with dates
What is the patient's smoking status?
What allergies does the patient have?
Please Read the Policy
We are committed to providing you with exceptional care. As well, we are committed to making our financial policies as simple and efficient as possible. Below you will find the policies that relate to how we bill and how we collect for services provided at WeDriveHealth. If you have an insurance plan that we accept: • We will bill your insurance for the visit • Your co-pay will be collected on the day of your visit • If your insurance requires a referral, it is your responsibility to obtain that referral from your PCP. If a valid referral is not on file, you will be asked to sign a referral waiver. If the referral is not sent to us, you will be responsible for the cost of services rendered. • Many insurance policies have an annual deductible, the amount you are required to pay out of pocket for medical expenses before your insurance company begins to pay. • Deductibles will be charged to your credit card on file, once the insurance company has confirmed the patient pay portion of your bill If you have an insurance plan that we do not accept: • Payment is due at the time of visit; we accept cash, checks, and credit cards • We are happy to provide you with a visit summary, which includes your diagnosis and visit codes. The summary may be submitted to your insurance company or Health Savings Account for reimbursement directly to you. In most cases, the insurance companies will pay a portion of your total bill. • Some of the services you receive here may not be covered by your insurance. If you and your provider agree that non-covered services are needed to provide you with the highest level of care or if you request a non-covered services, you will be asked to sign a statement indicating that you accept responsibility for payment in full. If you have no insurance or if you choose not to use your insurance for this visit: • Payment is due at the time of visit; we accept cash, checks, and credit cards • We offer same day, prompt payment discounts. Note that once a visit fee is discounted, you will not be eligible for reimbursement by your insurance company Assignment of Benefits I authorize my Payors(s) to pay directly to WeDriveHealth any benefits due under the terms of my health care plan(s), for services provided by WeDriveHealth. | understand WeDriveHealth reserves the right to refuse or accept assignment of medical benefits. If | am a Medicare beneficiary, I request payment of authorized Medicare benefits to me or WeDriveHealth on my behalf for any services furnished. If my health care plan(s) will not allow direct payment to WeDriveHealth or if WeDriveHealth chooses not to assect assignment of medical benefits, I agree to pay WeDriveHealth all healthcare payments I receive for services. I understand WeDriveHealth reserves the right to refuse or accept assignment of medical benefits. If I am a Medicare beneficiary, request payment of authorized Medicare benefits to me or WeDriveHealth on my behalf for any services furnished. If my health care plan(s) will not allow direct payment to WeDriveHealth or if WeDriveHealth chooses not to assect assignment of medical benefits, I agree to pay WeDriveHealth all healthcare payments I receive for services. I authorize WeDriveHealth to contact my payor(s) to obtain all pertinent financial information concerning coverage and payments made under my heath care plan(s) and for my payor(s) to release such information to WeDriveHealth.
I accept the terms and conditions .
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