New Patients

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Step 1 of 10 - Financial Policy Consent

Consent*
FINANCIAL POLICY

Thank you for choosing Columbus Arthritis Center as your health care provider. We are committed to providing you with quality medical care. Please understand that payment of your bill is considered part of your obligation as a patient.

The following binding terms and conditions are provided to communicate our Financial Policy and to avoid any misunderstanding concerning payment of services provided by our office. After reading the terms and conditions below you will be asked to acknowledge and agree to our Financial Policy. Please read and scroll downward through the terms and conditions below.

1.) Our office participates with a variety of insurance plans. It is your responsibility to:
• Bring your current insurance card to every visit and notify us of changes in coverage.
• Pay your copayment at each visit. Payment can be made by cash, check, MasterCard, Visa or Discover.
• Obtain any referrals your insurance carrier requires. Your appointment may be rescheduled if a referral is required and is not in place at the time of service.
• Pay any payment or reimbursement that you receive directly from your insurance company for services provided.
• Pay for any unpaid amounts that accrue as a result of you providing inappropriate insurance information for billing purposes.

2.) We will submit a claim to your insurance company for you. Balances not paid, per our contract by
your primary insurance company, may be billed to your secondary payer. A monthly statement will be sent to you. Ultimately, you are responsible for payment of charges including any co-insurance amounts, deductibles, or payments for non-covered services.

3. If you do not have insurance coverage or are insured by a company with which we are not contracted; a deposit of $150.00 for new patients or $50.00 for established patients is expected prior to delivery of services. If you do not have insurance coverage we offer a discount of 30% when balance due is paid in full on the date of service. We understand the financial burden that this may present and therefore will be offering an additional credit option for those interested.

4. If you have questions about your insurance, we will be happy to assist you. Specific coverage issues however, should be directed to your insurance company's member services department (the contact number is on your insurance card).

5. All balances billed are due within 30 days of the statement date. Unpaid balances greater than 30 days are subject to our collection process. Accounts sent to our collection agency are subject to a 35% surcharge.

6. A finance charge will be added to any balance over 60 days at the rate of 1.5% per month or 18% per annum.

7. A fee of $125.00 for a new patient or $25.00 for an established patient will be charged for all appointments that are not kept or cancelled within 24 hours prior to the appointment time. Upon request, your physician may agree to waive this fee for unforeseen circumstances.

8. There is a fee of $25.00 on all returned checks.

9. There is a fee to copy any and all medical records based on the number of pages copied, after a one time courtesy.

10) Your physician may order a procedure to be performed either in our office or outside the office; you will need to contact your insurance provider to check your benefits for outpatient procedures. This coverage determination is not a guarantee of payment and is subject to coverage and benefits at the time of service. You may also ask our office for the procedure/diagnosis codes to verify that the procedure is a covered benefit.

Thank you for reviewing and understanding our financial policy. Please let us know if you have any questions or concerns by calling 614-486-5200.

BY CLICKING “I AGREE’ BELOW, I CERTIFY THAT I HAVE READ THE TERMS AND CONDITIONS ABOVE AND I WILL PAY THE COLUMBUS ARTHRITIS CENTER ANY COPAYMENTS, CO-INSURANCES, DEDUCTIBLES OR NON-COVERED SERVICES. I WILL IMMEDIATELY PAY TO THE COLUMBUS ARTHRITIS CENTER ANY PAYMENT THAT I RECEIVE FROM MY INSURANCE COMPANY OR REIMBURSEMENT SERVICE FOR SERVICES PROVIDED TO ME. I WILL ALSO BE RESPONSIBLE FOR ANY AMOUNTS NOT PAID BY INSURANCE DUE TO NOT PROVIDING THE APPROPRIATE INSURANCE INFORMATION FOR BILLING PURPOSES. I WILL PAY ALL FEES AND CHARGES THAT BECOME DUE UNDER THE TERMS AND CONDITIONS OF THE FINANCIAL POLICY ABOVE

BY CLICKING “I AGREE” I AM ACKNOWLEDGING AND AGREEING TO THE TERMS AND CONDITIONS OF THE FINANCIAL POLICY ABOVE.

I agree to the financial policy.

Financial Interest Disclosure Form

To Our Patients Being Referred for MRI:

We wish to notify you that the physicians of the Columbus Arthritis Center, Inc are owners of the MRI services located at 1211 Dublin Rd, Columbus, OH 43215

We refer our patients to this location because we believe our staff provides quality medical care and excellent service to our patients. The services are convenient to our patients in terms of location, access, scheduling, hours of operation, and continuity of care.

We believe that our patients have a choice in the selection of facility where they may receive their care. If you prefer to obtain radiology services at another facility, please let us know and we will refer you to the facility of your choice. Below is a list of other facilities providing MRI services in this area. Please note that inclusion in this list is NOT an endorsement or recommendation of these providers or suppliers by Columbus Arthritis Center, Inc.
- Advantage Diagnostics
  
  1430 South High Street
  
  Columbus, OH 43207
  
  614-220-0001
- Riverside Methodist Hospital
  
  3535 Olentangy River Rd
  
  Columbus, OH 43214
  
  614-566-1111
- Center for Diagnostic Imaging
  
  866 West Broad Street
  
  Columbus, OH 43222
  
  614-221-4860
- Dublin Methodist Hospital
  
  7500 Hospital Drive
  
  Dublin, OH 43016
  
  614-566-1111
- Polaris Open MRI
  
  2141 Polaris Parkway
  
  Columbus, OH 43240
  
  614-841-0800
- Ohio State University Medical Ctr
  
  410 W 10th Ave
  
  Columbus, OH 43210
  
  800-293-5123
- ProScan Imaging Dublin
  
  4351 Dale Drive, Suite 100
  
  Dublin, OH 43017
  
  614-855-8740
- Mount Carmel Health - West
  
  739 West State Street
  
  Columbus, OH 43222
  
  614-234-5000
- ProScan Imaging-Pickerington
  
  417 Hill Rd N
  
  Pickerington, OH 43147
  
  614-855-8740
- OhioHealth Doctors Hospital
  
  5100 West Broad Street
  
  Columbus, OH 43228
  
  614-544-1000
These other facility addresses are NOT for your initial consult at Columbus Arthritis Center. Our providers are not at these other locations.

Insurance Information
Primary Insurance
Subscriber
Relationship to Patient
Insurance Policy Holder's Date of Birth
MM slash DD slash YYYY
Insurance Policy Holder's SSN
Primary Insurance ID Number
Primary Insurance Group Number
Secondary Insurance
Subscriber
Relationship to Patient
Insurance Policy Holder's Date of Birth
MM slash DD slash YYYY
Insurance Policy Holder's SSN
Secondary Insurance ID Number
Secondary Insurance Group Number
To Be Notified In Case of Emergency
Emergency Phone
Pharmacy Name
Pharmacy Phone
Pharmacy Address
Street Address City State ZIP Code
Mail Order Pharmacy
Mail Order Phone
Mail Order Address
Street Address Address Line 2 City State ZIP Code
Other Physicians
Identification of other physicians involved with my medical care whom I authorize ongoing release of information for continuity of care:
Referring Doctor
Referring Doctor Phone
Referring Doctor Address
Street Address Address Line 2 City State ZIP Code
Provider
Phone Number
Address
Street Address Address Line 2 City State ZIP Code
Type of physician / health care provided:
Provider
Phone Number
Address
Street Address Address Line 2 City State ZIP Code
Type of physician / health care provided:

General Consent
Patient Name
Date of Birth
Home Address
Street Address Address Line 2 City State ZIP Code
Primary Phone Number
Provider
I am requesting that health care services be provided to me (or my minor child or the patient named above) at Columbus Arthritis Center (“CAC”). I voluntarily consent to all medical treatment and health care related services that the caregivers at CAC consider to be necessary for me (or the patient named below). These services may include diagnostic, therapeutic, imaging, and laboratory services. My blood may be used to perform routine quality assurance testing. I am aware that the practice of medicine and surgery is not an exact science; no guarantees have been made to me about the results of treatments or examinations.

I understand that I have the right to discuss any treatment plan with my physician about the purpose, potential risks and benefits of any test ordered for me. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I further understand that if I have any concerns regarding any test or treatment recommended by my health care provider, I am encouraged to ask questions.

I understand that my protected health information may be used or disclosed by CAC for my treatment, to obtain payment for this treatment, for its health care operations and in accordance with CAC’s Notice of Privacy Practices. I also understand that my protected health information will be disclosed to other CAC affiliates if needed for the purpose of furthering my treatment, to obtain payment for treatment, and for its health care operations, and I consent to the practices contained in this section.

Financial Responsibility: Subject to applicable law and the terms and conditions of any applicable contract between CAC and a third-party payer, and in consideration of all health care services rendered or about to be rendered to me (or the below-named patient), I agree to be financially responsible and obligated to pay CAC for any balance not paid under the “Assignment of Benefits/ Third Party Payers” paragraph below;

OR Subject to applicable law and in consideration of all health care services rendered or about to be rendered to me (or the below named patient), I agree to be financially responsible and obligated to pay CAC for the patient balances due.

Assignment of Benefits/Third-Party Payers: In consideration of all health care services rendered or about to be rendered to me (or the below-named patient), I hereby assign to CAC all right, title, and interest in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers of an amount not exceeding CAC’s regular and customary charges for the health care services rendered. I authorize such payments from applicable insurance carriers, third party payers, and other third-parties. A list of usual and customary charges is available upon request. I consent to any request for review or appeal by CAC to challenge a determination of benefits made by a third-party payer. Except as required by law, I assume responsibility for determining in advance whether the services provided are covered by insurance or other third party payer.

I consent to receive, on the cellular phone and/or other telephone number(s) that are provided to CAC on this form or updated at a later time, text messages and/or telephone calls or other communications using live, artificial or prerecorded voices, automatic telephone dialing systems, or any other computer-aided technologies from CAC and its affiliates, clinical providers, and business associates, along with any billing services, collection agencies, agents, or other third parties who may act on their behalf. Such text messages and/or telephone calls may be related to any purpose, including those related to my account and/or the care rendered. I understand this consent to communications is not required to receive services from CAC or any of the other authorized callers and that data usage and other charges may apply. I may revoke this consent to these communications at any time.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Name of Signatory
Relationship to Patient

(if Applicable)
Signature of Patient

(18 years old or older) or Legal Guardian
Date
MM slash DD slash YYYY
Acknowledgment of Receipt of Notice of Privacy Practices

HIPAA requires that CAC give you a Notice of Privacy Practices that describes how CAC will use and disclose your protected health information and explains your HIPAA Privacy Rights.

I have read the Notice of Privacy at www.columbusarthritis.com under the “FORMS” tab or received a copy of the Notice of Privacy Practices.
Signature of Patient

(18 years old or older) or Legal Guardian
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

New Patients

Step 1 of 10 - Financial Policy Consent

Financial Interest Disclosure Form

Advance Directive Notice

Patient Information

Insurance Information

Other Physicians

Symptoms

Vaccinations

Rheumatology Past History

Medical Past History

Surgical Past History

Family History

Social History

Current Medications

Allergies

Past Medications

Information Release Authorization to Friends / Family

General Consent

Year

Year

Year

Year