Arthritis Associates

ARTHRITIS ASSOCIATES 33920 US 19 N SUITE 241 PALM HARBOR, FL 34684

Phone 727-773-9793 Fax 727-773-0674

Anthony I. Sebba, MD Linda Mangione, PA-C Sandra Shanaberger, PA-C

Dear______,

Welcome to Arthritis Associates.

This letter is to confirm your appointment for a consultation on______at______.

If you are unable to keep your scheduled the appointment, please notify us within 24 hours. Many patients are in need of an appointment, and we reserve the right to bill for appointments cancelled without 24 hours advance notice.

Directions to our office are located on page 2 on the back of this sheet.

The items below needed from you or your referring physician prior to your scheduled appointment.

1. Please complete the attached documentation and bring it with you to your appointment. 2. Please be sure to arrive 20 minutes early. 3. Please make sure you or your referring physician provide to us all relevant tests including laboratory results, X-rays, MRI, and CAT scans. Please ask your physician the reason for your appointment here. 4. If you participate in an HMO and require an authorization to see a specialist, please make sure your referring physician sends it within 24 hours of your scheduled appointment.

We thank you in advance for providing all of the required documentation.

Sincerely,

The staff members of Arthritis Associates Arthritis Associates 33920 US Highway 19N Suite 241 Palm Harbor, FL 34684 Phone 727-773-9793 Fax 727-773-0674

FROM THE SOUTH:

US 19 NORTH – TO NEBRASKA. GO LEFT ON NEBRASKA AND TAKE A RIGHT JUST AFTER THE HESS GAS STATION INTO THE PARKING LOT. DRIVE TO THE FRONT OF THE BUILDING WHERE THERE IS HANDICAPPED AND PATIENT PARKING. OUR OFFICE IS LOCATED ON THE 2ND FLOOR.

IF YOU PREFER TO STAY OFF OF US 19 YOU CAN TAKE BELCHER ROAD NORTH AND GO RIGHT ONTO NEBRASKA AND TAKE A LEFT JUST BEFORE THE HESS GAS STATION.

FROM THE NORTH:

US 19 SOUTH – GO PAST ALDERMAN. JUST BEFORE YOU REACH NEBRASKA YOU WILL SEE THE HARBOR PARK SIGN ON THE RIGHT JUST AFTER WENDY’S. OUR OFFICE IS BEHIND VERIZON AND STARBUCKS. WE ARE ON THE 2ND FLOOR (SUITE 241). Anthony I. Sebba, M.D., P.A. Patient Information

Name______Today’s Date______

Date of Birth______SSN______

Address______City______State_____Zip______

Home Phone______Work Phone______Cell Phone______

Marital Status______Sex______

Employer Name & Address______

Emergency Contact (outside your home)______

Relation to you______Phone Numbers______

Pharmacy______Pharmacy Phone______

Primary Care Physician______Phone______

Address______

Referring Physician______Phone______

Address______

Primary Insurance Company______

Who is the policyholder?______

Policyholder SSN ______DOB______Employer______

Secondary Insurance Company______

Who is the policyholder?______

Policyholder SSN______DOB______Employer______

Seasonal Address______

Phone______Usual Months at this address______Arthritis Associates, PA Anthony I. Sebba, MD

FINANCIAL AGREEMENT Please read the following items regarding our billing policies and procedures. This is an agreement between the patient and Arthritis Associates.

-It is your responsibility to give us your correct insurance information. If there are changes in your insurance coverage, please provide us with a copy of your new card immediately. If you do not inform us of insurance changes, you may be responsible for charges.

-Co-payments and co-insurance are due at the time of service. We accept checks, credit cards or cash. If you do not pay your co-pay at the time of service, there will be a $10.00 billing charge. Returned checks will have a $35.00 charge added to the amount due.

-Medicare. We will accept assignment on all covered charges by Medicare. As a courtesy to you, we will also file your secondary insurance. If your secondary does not pay in a timely manner, we may bill you. If you do not have secondary insurance, you will be responsible for 20% of all charges approved by Medicare at time of service.

-HMO and PPO’s. If we are contracted with your insurance company, we will file your claim. You are responsible for all deductible and coinsurance amounts. If your insurance requires you to have a referral or authorization, you must bring it with you or verify that we have received it prior to your visit. We do not call your primary physician’s office to obtain your referral. If you do not have required authorization for your visit, you will need to re-schedule your appointment or will be responsible for any costs incurred.

-For other private non-contracted insurance policies. We will file your claims to your insurance company as a courtesy to you. If your insurance company does not reimburse us an amount that is reasonable and customary, we may bill you for the difference. If they do not pay us in a reasonable amount of time, we may bill you.

-Missed Appointments. Office policy is to bill for appointments missed or cancelled without 24 hours notice.

A COPY OF THE NOTICE OF PRIVACY PRACTICES HAS BEEN MADE AVAILABLE TO ME.

______PATIENT SIGNATURE All Patients Please Read and Sign Below

FOR MEDICARE PATIENTS: I request that payment of authorized Medicare benefits be made to Anthony I. Sebba, M.D., P. A. for any services furnished. I authorize any holder of medical information about me to release to the Health Care Finance Administration and its agents, any information needed to determine these benefits. I also request that payment for authorized Medigap benefits be made on my behalf to Anthony I. Sebba, M. D., P. A. for services provided. I authorize any holder of medical information about me to release to my Medigap insurer any information needed to determine these benefits.

______Beneficiary Signature Date

FOR NON-MEDICARE PATIENTS: I authorize release of any medical information necessary to process this claim and related claims. I request that payment of authorized benefits be made on my behalf to the physician for any services furnished to me.

______Patient Signature Date

ALL PATIENTS: I understand that it is my responsibility to inform this office immediately of any change in my insurance coverage. I understand that I may be held financially responsible for any and all fees that are not reimbursed by my new insurance company if I do not inform this office before the fees were incurred of the insurance change. I agree to pay all charges promptly, upon presentation thereof. Charges as shown by statements are agreed to be correct unless protested within 30 days. It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims thereon. In the event that legal action should become necessary to collect an unpaid balance due, I agree to pay reasonable attorneys fees or other such costs. If my account is forwarded to TransWorldSystem a collection fee of $12.50 will be added to charges. If my account is forward to Credit Management Services a fee of 50% of the balance due may be added to charges.

______Patient Signature Date

I hereby authorize Arthritis Associates to speak with the following person(s) regarding my health care: ______DatePatient Signature:______