METROPLEX PULMONARY & SLEEP CENTER, P.A 4833 Medical Center Drive, Suite 6B McKinney, Texas 75069 Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
You can request your medical records to be mailed to your house. We will send those to you by USPS Certified mail and with signature confirmation. However, you must send us a written and signed request if you wish to receive your medical records via email.
I request that payment of authorized insurance benefits be made on my behalf to Metroplex Pulmonary and Sleep Center for any services furnished by the provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration, and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.
I acknowledge that Metroplex Pulmonary and Sleep Center provided me with a written copy its Notice of Privacy Practices.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
It is necessary for our office to enact the following policies effective January of each year due to the increase in high deductibles, co-insurance portions, co-payments of insurance companies’ pending claims and withholding payments. I hereby give authorization to Dr. Shahrukh Kureishy/Dr. Ferzana Mir and their staff to provide medical treatment. I understand that no guarantees have been made with regards to treatment success, and that there may be complications associated with the condition or with its proposed treatment. Please initial
We ask for your insurance information when we schedule your first appointment as well as at each of your follow-up to revise any changes. We do our best to verify that our doctors are contracted, and in network with your insurance plan to cover your office visit, PFT Pulmonary Function (breathing) Test, sleep study take home device Test, Labs (orders sent out), CPAP, or CPAP Supplies and Spirometry might not be paid by your insurance. By signing below you are agreeing to pay for these services yourself if those services are denied by your insurance or determined by your insurance as not to be “medically necessary.”
Based upon information provided to us by your insurance company we will expect payment according to the benefits quoted. Your copayment, co-insurance or deductible per your insurance company, and as indicated on most insurance cards will be collected before seeing the doctor. We will then file your office visit superbill with your insurance company. However, you will be responsible for your portion after your insurance pays, and as it indicates on your EOB. Any outstanding balance will be due and payable upon receipt of the statement. Also, we will not be held responsible if you or your accompanied person/s fall and injures in or outside our office. Furthermore, many insurance plans have a requirement that patients must provide additional information to them before they will pay your claim. When this is the case, your insurance company will inform us that they have “pended” your claim for additional information. Therefore, the full balance due on your visit becomes your responsibility. Once an insurance company “pends” a claim there is nothing that our office can do to get the claim paid. It is completely your responsibility to contact your insurance company to provide them the needed information so your insurance company pays the claim within thirty days. Additionally, you must notify us at the time of service if your insurance plan, group, or policy number changes so we can file your claim precisely.
Visits that have been filed by us in a timely manner but denied by your insurance after sixty days will become your responsibility. Please remember that our office files to your insurance as a courtesy to you. It is important to remember that your insurance policy is a contract between you and the insurance company.
I also understand that failure to appear on scheduled follow up or new patient visit appointment may result in a delay in the diagnosis, and treatment of a potentially serious condition. We call in advance to remind an upcoming appointment, and/or reschedule if the appointment cannot be kept. However, we will not be held responsible for complications arising from missed appointments due to the patient’s noncompliance.
We reserve the right to charge $35 for missed appointment and no show not given (48 hours’ notice by the patient.) Returned checks for insufficient funds will be subjected to $35 fees as well. Payment is expected at the time of service.
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