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Appointment Information: Patient: ______________________________ Date: ________________________________ Time: ________________________________
Thank you for choosing our office for your surgical consultation. To assist us in providing you with the best care possible, please bring the following with you to your appointment:
We value your time and want to provide you with a comprehensive and in-depth evaluation. To do so, please allow up to two hours in our office for your appointment. If you have any questions prior to your scheduled appointment, please contact our office at 865-692-1610. For more information, you can also go to our website, www.aaronmd.com.
If your insurance has been purchased through the Affordable Healthcare Marketplace, please verify with your carrier that Dr. Margulies is an “in-network provider” by calling the number on the back of your insurance card.
We look forward to meeting you and providing you with compassionate surgical care that you can trust.
Sincerely, Aaron G. Margulies, MD, FACS Breast Surgical Oncologist / General Surgeon
By signing below, I verify that all the information above is correct. I also verify that I have been offered and have reviewed a copy of the Patient Privacy Notice required by HIPAA and understand my right to privacy as a medical patient of Aaron G. Margulies MD, PLLC.
At the office of Aaron G. Margulies, MD, PLLC, we strive to give you the best possible care. In order to serve this purpose, it is important that our patients understand the process of reimbursement. Please read this Financial Responsibility Form and sign to acknowledge that you understand your accountability.
It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations, as well as, authorization requirements. This information can be obtained by contacting your insurance carrier.
We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of the visit, the financial responsibility for any payment due will be yours.
*If you have any changes in your insurance coverage you must notify us prior to your appointment.
The deductible is determined by your individual contract with your insurance carrier. You are responsible for your deductibles, copayments, and coinsurance. Your insurance company expects us to collect them from you at the time of service. Understand that you will be expected to pay deductibles, coinsurance and copayments, when this applies.
All patients are responsible for account balances if their insurance carrier denies payment for services rendered because they were stated as “non-covered services” or deemed as “medically unnecessary.” To avoid this, please check with your insurance carrier prior to receiving any treatment or services.
By signing below, I authorize the release of any medical information necessary to process insurance claims filed to my insurance carrier on my behalf or on the behalf of my dependents. I authorize payment for medical benefits to be made directly to my physician for services rendered at the office of Aaron G. Margulies, MD, PLLC.
I certify that I have read the above disclosure statements, understand my responsibilities, and agree to the terms written above.
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