Please find enclosed our Patient Registration Forms (4 pages)
Please print and complete these pages prior to your appointment
We are required to make a copy of your insurance card(s) and photo identification and perform other administrative tasks prior to your first appointment. Therefore, if possible, please arrive 15 minutes early to your first appointment.
Please note: Without registrations forms and initial medical history questionnaires completed, you may be asked to reschedule your first appointment.
To confirm or schedule your appointment, please call our office at (734) 929-2696
We look forward working with you!
Tony L. Boggess DO, PC
Amy F. Saunders MD, PLLC
Suite #14&15,Second floor,1310 S. Main Street, Ann Arbor, MI 48104
Phone: (734) 929-2696 Fax: (734) 929-2703
Our office is located at 1310 S. Main Street, 2nd Floor, Ann Arbor, MI in the Stadium Commons building. We have free covered parking directly under the building off Main Street.
If unable to keep your appointment, kindly give us 24 hours notice
Tony L Boggess DO, PC/ Amy F Saunders MD, PLLC
New Patient Registration Form
Patient’s Name:______SS #______
First Name MI Last Name
Date of Birth:______oMale oFemale oSingle oMarried Cell Ph:( ____ ) ______
Street Address (incl. Apt #):______Email:______
City/State/Zip Code:______Home Ph:( ____ ) ______
If patient is a Minor, are parents oMarried oDivorced Custodial Parent:______
Home Phone:( ____ ) ______Work Phone:( ____ ) ______SS #______
In case of emergency, CONTACT (not living with you):______
Phone:( ____ ) ______Relationship to Patient:______
Cell Ph [Dad]:( ____ ) ______Cell Ph [Mom]:( ____ ) ______Fax Line:( ____ ) ______
Father’s Name:______SS #______
First Name MI Last Name
Employer:______Work Ph:( ____ ) ______
Mother’s Name:______SS #______
First Name MI Last Name
Employer:______Work Ph:( ____ ) ______
Referring Physician’s Name:______Phone:______
PLEASE PRESENT INSURANCE CARD(S) & PHOTO ID FOR COPYING AND COMPLETE THE REQUESTED INFORMATION
Insurance Company (primary):______Phone:______
Primary Insured’s Name:______Date of Birth:______
Policy #:______Group #:______Relationship:______
Insurance Company (secondary):______Phone:______
Primary Insured’s Name:______Date of Birth:______
Policy #:______Group #:______Relationship:______
I authorize Tony L. Boggess, DO/ Amy F. Saunders, MD to treat me and to use my personal health information for continuity of health care operations.
______
Patient’s Signature (OR Parent if patient is a Minor) Date
********************************
I have been shown the HIPAA Privacy Policies, describing how this office utilizes and protects my private health information, and offered a copy of them. My signature and date below, I acknowledge receiving and understanding these HIPAA policies as they relate to my care under Tony L. Boggess, DO.
______Date ______
Patient’s Signature (OR Parent if patient is a Minor)
1310 S. Main St. Ann Arbor, MI 48104 Phone: 734-929-2690 Fax: 734-929-2703
consent for treatment (general)
I hereby authorize Tony L. Boggess, DO/ Amy F. Saunders, MD (“Physician”), Physician’s associates and Physician’s employees to provide services to me / my child and to perform any examinations, treatments, diagnostic tests or procedures which, in Physician’s judgment, may be advisable.
Physician will explain the services and treatment I/my child will be receiving, including a description of the purpose, method, significant potential risks/complications, and alternatives. Physician will also explain the consequences of non-treatment. I understand that I have an opportunity to ask questions and understand that the Physician’s responses should be satisfactory to me prior to agreeing to treatment. Informed Consent Agreements will be presented as appropriate according to treatments suggested by Physician.
I understand that medicine is not an exact science and that all possible outcomes and/or complications cannot be anticipated and that no implied or expressed promises or guarantees will be made. I further understand that some of the treatments and medical therapies recommended by Physician may be innovative, not widely accepted and may not meet the established standard of care. These treatments may also not be supported by clinical research. In addition, some of these treatments may have side effects, including worsening symptoms and adverse changes in laboratory test results. Such side effects may be temporary or permanent.
I understand the importance of my participation in my/my child’s treatment. I agree to abide by the medical plan prepared by Physician and to not make any changes in the medical plan without first consulting with Physician. I agree to maintain those records requested by Physician and to communicate any concerns about the treatment or side effects to Physician, as soon as possible.
I authorize Physician to retain the services of other professionals or health care providers, whose services are considered necessary by Physician, to assist Physician. I understand and agree that charges for services provided by these individuals are separate and distinct from those of the Physician.
In consideration for services rendered or to be rendered to me/my child by Physician, I hereby assign to Physician and authorize payment directly to Physician of any insurance benefits or other payments by third parties otherwise payable to me. I understand I am financially responsible to Physician for charges not covered by any insurance.
I specifically acknowledge that no guarantees of any kind have been made to me as to course, duration, or result of the treatment. I give this general consent to treatment and the use of complimentary/alternative modalities voluntarily on my behalf and on behalf of my child, for whom I am the legal representative. I come to this arrangement as an informed consumer specifically seeking conventional, natural, and alternative approaches from Tony L Boggess, DO/ Amy F Saunders, MD (Physician).
For purposes of consent and registrations above and below, I acknowledge understanding as to the contents requiring my signature as (choose one option below):
Patient (please print clearly): ______Date:______
Patient Signature: ______
Or
Authorized persons, Guarantor (please print): ______Date:______
Authorized Signature: ______
Relationship: ______(parent, guardian, etc.)
Statement of Patient Financial Responsibility
We appreciate the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.
You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. Most insurance companies require you pay the copays and/or deductibles at the time of service, and may have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, or if you or your physician elects to continue care past your coverage period, you will be responsible for your balance in full.
I have read the above policy regarding my financial responsibility to Tony L. Boggess, DO, Amy F. Saunders, MD for the above named patient. I certify that the information I’ve provided to Dr. Boggess/ Dr. Saunders is, to the best of my knowledge, true and accurate. I authorize my insurer to pay the full amount (less deductible and co-payment/co-insurance) of bill incurred by the above named patient directly to Tony L. Boggess, DO/ Amy F. Saunders, MD.
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)
Consent for Treatments and Authorization to Release Information
I hereby authorize Tony L. Boggess DO, PC/ Amy F. Saunders MD, PLLC through its appropriate personnel, to perform appropriate assessment and treatment procedures on the above named patient.
I further authorize Tony L. Boggess DO, PC/ Amy F. Saunders MD, PLLC to release any information required to effect treatment and continuation of care relating to the above named patient (this does not affect your HIPAA privacy rights).
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)
Cancellation / Self Pay
We understand there may be times when you may miss an appointment due to emergencies or unforeseen obligations to work or family. We request you call with 24-hours notice for canceling of an appointment to avoid missed-appointment “no-show” fee of $75.00. I also understand that if I “no-show” for multiple appointments, or cancel multiple consecutive appointments, I may be discharged from care. In that case, Dr. Boggess/ Dr Saunders will notify you in writing, via certified mail, should you be discharged from care. I have read and understand the above Cancellation / No Show Policy, and I agree to the terms described:
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)
Self-Pay
IF YOU DO NOT HAVE HEALTH INSURANCE: I do not have health insurance and will be financially responsible for services rendered to me by Tony L. Boggess, DO/ Amy F. Saunders, MD. Unless a written payment plan had been established otherwise, I agree to pay Tony L. Boggess, DO/Amy F. Saunders, MD the full and entire amount for the treatment given to the above named patient at the time of each visit.
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)
Supplements/Nutraceuticals:
Our practice carries a range of high quality supplements/nutraceuticals that are manufactured by companies of the highest integrity in their industry. Some higher potency nutraceuticals are, by choice of the manufacture, not available to the public in an over-the-counter fashion, but are made available via qualified professionals to ensure their safe and appropriate use.
We never require you to purchase nutraceuticals/supplements/or other products from our practice, and your care is not affected by your decision not to. If you do decide to purchase products elsewhere, you will be encouraged to purchase the same trusted brands and products we use whenever possible. All private label “Natural Balance” supplements have equivalent public names that can be purchased elsewhere if needed and/or desired. We make it a point to offer most products to our patients below suggested retail prices.
Whenever purchasing products through our office you’ll be asked to sign a disclosure statement regarding the voluntary and financial nature of the transaction. You will also be able to ask questions and have them answered to your satisfaction regarding the use and purpose of all suggested nutraceuticals.
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)
(Almost Done J)
Patient Care Insurance agreement
In consideration for undertaking my care, I agree to the following:
In the event my insurance company does not make payment to you within ninety (90) days of your billing, I will become personally responsible for the amount billed and authorize payment on the credit card listed below.
In those instances in which my insurance company has made partial payments, I also authorize you to collect outstanding balances for uncovered services rendered on the credit card listed below.
In the event I do not appear for a scheduled appointment for good reason without 24 hours notice I authorize a charge of $75.00 per occurrence on the credit card listed below.
Name:______
Credit Card Type: MasterCard Visa Discover American Express
Card Number: ______Expiration Date: ______
Signature: ______Today’s Date: ______
Email, Phone Consults, and Office Hours
Re Email: I, (please print name) ______, hereby understand that Email communication with Dr. Boggess regarding my care is not encouraged. HIPAA regulations state that all patients must be made aware of potential threats to their private health information. Therefore, I understand that Email is not HIPAA compliant or secure. I have been made aware of the possibility that private health information can be revealed through Email to unattended parties deliberate, accidental, or otherwise. For this reason, Dr. Boggess does not routinely engage in patient care via email correspondence.
Re Phone Consults: Whenever possible,a face-to-face encounter is the best way to evaluate progress and provide personal care. But if needed, Dr. Boggess does offer telephone consultations. The cost of the telephone consultations are: 5 – 10 minutes $30, 11-20 minutes $60, 21 – 31 minutes $90. You will be provided a receipt with a billable code.Many insurance companies will reimburse such activities, but not always. It’s best to call your insurance company and inquire if such services are covered under your specific contract.
Our clinicians and staff will be able to answer brief questions without an appointment. However, anything that requires medical record review, or needs to be addressed more methodically will require a scheduled appointment over the phone or in person.
Re Office Hours: Our office hours fluctuate throughout the year to meet the needs of our patients. We offer evening availability during the school year, but generally keep a standard 9-5 schedule during the summer months. We are closed weekends and holidays.
Patient Signature ______Date ______
Guarantor Signature ______Date ______
(If patient is a dependent minor)