Please read the following information prior to completing the Patient Questionnaire in the Patient Portal in which you will provide financial/billing information.
You will be asked to sign a copy of this form to confirm your consent(s), and to confirm your financial information when you check in for your appointment. If needed, you will be able to review your financial information prior to signing.
At the time of your visit you must bring in a government issued picture ID and your insurance cards.
Release of Benefits and Information
I consent for medical treatment, and I confirm that the insurance information listed on this form to be complete and accurate. I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or the insurance company to release any information required for this claim.
Financial Arrangements Policy
We are dedicated to providing outstanding medical care to our patients. We do our utmost to be helpful and informative in the are of financial obligation. If you ever have any questions concerning this policy, or your part in it, please ask. Please read the following explanation of our financial arrangements policy. The payment options will be listed on the questionnaire. You can select the payment option that would be the best for you.
Patients Without Insurance
If you do not have insurance, we expect payment in full at the time of service. For your payment convenience, we accept cash, check, money order, Visa/Mastercard, Discover and American Express. You may also choose to leave your signature and credit card number on file; with your authorization, we will charge your card monthly for your personal account balance. Should your account balance become delinquent and assigned to a collection agency, you will be discharged from the clinic and we will no longer provide care for you.
Patients With Insurance
Due to the fact that insurance policies can be confusing and differ widely in coverage, we will do our best to assist you. We will prepare and file your insurance claims for you. We will also wait up to 40 days for their portion of the billed charges. Under this arrangement, you are responsible for paying your co-pay, any non-covered portions, and any deductible you have yet to cover. For your payment convenience, we accept cash, check and money order, Visa/MasterCard, Discover and American Express. You may also choose to leave your signature and credit card number on file; with your authorization, we will charge your card monthly for your personal account balance. Bear in mind that you are responsible to know and understand your insurance policy and are ultimately responsible to pay Valley Medical Care for your entire account balance regardless of your insurance company’s payment schedule. Should your account balance become delinquent a $6.00 per month billing charge will be assessed to your account. If the delinquency continues for 90 days, your account will be assigned to a collection agency, you will be discharged from the clinic and we will no longer provide care for you.
We file claims to your insurance as a courtesy to you. You are expected to pay your deductible and copays at the time of service. If we have not received payment from your insurance within 60 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges regardless of insurance status.
If you need assistance please contact our billing department between 8:30am and 4:30pm M-F at 907-586-2482.
Electronic Medication History and Insurance Prescription Benefits
Our electronic medical record program enables us to review your electronic medication history (prescriptions you have filled) to help us verify the medications you are currently taking. This aids the provider in making appropriate choices for treatment.
We can also verify your prescription medication coverage so that we may prescribe appropriate medications that will be covered by your insurance plan.
Your consent is needed for us to obtain this information. You can select to give or withhold consent on the questionnaire.
Acknowledgement of Receipt of Notice of Privacy Practices for all Health Information
You have the following options for viewing our Notice of Privacy Practices. You may obtain a paper copy from the office, you can read/print a copy from our website (www.valleymedicalcare.com), or you may read a posted copy at our office. Your signature on this form will be your acknowledgement of receipt of this document in one of the available formats.
Valley Medical Care participates in a Hospitalist program while treating our patients who may be admitted to Bartlett Regional Hospital for care or observation. As a patient of Valley Medical Care, you agree to medical care by any of our physicians/nurse practitioners acting in the hospitalist role. If you have any adverse feelings about treatment from any specific VMC physician/nurse practitioner, you should seek primary care with another primary care practice. By signing this agreement, you agree to treatment by any of our practitioners in the hospital setting.
All patients of Valley Medical Care become inactive after 3 years without appointments or treatment. If you fall into an inactive status and want to resume care with VMC, you may be asked to fill out a “New Patient Request Form”.