PRACTICE PROCEDURES AND POLICIES

Practice Procedures

Important practice procedures and policies are outlined below. Please read each point carefully and initial where indicated to acknowledge your understanding.

Initials: I understand that I must allow at least 72 hours for prescription refills.

Initials: I understand that a follow-up visit with my physician may be required to obtain additional refills of my medications.

I agree to take all medication(s) exactly as instructed.

Initials: I understand that I am not permitted to change the dosage or alter the timing of my medication(s) without first consulting my physician. I also understand that narcotic medications will not be called after hours, on holidays, or on weekends.

Initials: I must keep all appointments as recommended. If I miss an appointment three times without notifying the practice in advance to cancel, I will be responsible for a no-show fee for each time, and the practice reserves the right to discharge me as a patient.

Appointment and Cancellation Policy

I understand that Auria Medical Clinics requires at least 48 hours' notice to cancel or reschedule a follow-up or test appointment. Failure to comply with this policy may result in a charge, and I will be responsible for paying the current no-show fee.

Insurance and Payment Responsibilities

I am aware that I am responsible for following my insurance company's requirements regarding referrals or pre-authorization. If I do not comply, I will be responsible for full payment of services.

I also understand that I am responsible for any co-payment due at the time of service and any other amount not covered by my insurance company.

I authorize Auria Medical Clinics to release any necessary information to insurance companies for payment of medical services. A copy of this authorization is as valid as the original.

Returned Checks and Collections

I am aware that there will be a $50.00 fee for any check returned by my financial institution.

If my account is sent to a collection agency, any additional charges or legal fees incurred will be added to my account balance.

Practice Termination Policy

Termination:

A patient may be discharged from the practice with 30 days' notice for noncompliance with these policies.

The following actions are grounds for immediate termination:

• Obtaining narcotics from another physician while under the care of our physicians or altering or forging a prescription. This is a federal felony, and it will be reported to authorities.
• Using inappropriate language or behaving violently, whether over the phone or in the office.

Acknowledgment

I have read, fully understand, and agree to the policies stated above.