Quiroz Adult Medicine Clinic, P.A. General Office Policies

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Quiroz Adult Medicine Clinic, P.A.

General Office Policies

Thank you for choosing Quiroz Adult Medicine Clinic P.A. (QAMC) as your health care provider. The following general office policies are provided to understand our office protocols and further enhance our professional relationship. Please review and initial each of the policies and sign at the bottom of the page.

_____HMO Referrals: If your insurance plan requires a written authorization or referral for a medical specialist from our office, you must notify the clinic five (5) business days prior to your specialist appointment to ensure the authorization or referral is processed and sent to the specialist office.

_____PRE-CERTIFICATION: If your plan requires a pre-certification of a non urgent radiology test please allow up to three (3) business days to obtain.

_____PRESCRIPTION REFILL: Please contact your pharmacy for prescription refills before calling the clinic. It will ensure that you are prescribed the correct medication, from the correct pharmacy and prevent refill errors. Allow for routine medication refill requests a 24 hour window for completion but are generally done by the end of the business day. If insurance company request additional information for approval this may cause a delay. Holidays and weekends may also delay the fulfillment of prescription refill requests. Routine refills will not be

processed after business hours or on weekends.

_____AFTER HOURS CARE: If you are having a medical emergency please call 911. If you are experiencing a non life threatening emergency call the office main number 210/404-0127 the answering service will notify the on call physician. Please contact QAMC the following business day to schedule a follow up appointment regarding an emergency visit. General questions can be sent to QAMC staff 24/7 via our patient portal.

_____HOSPITAL CARE: If you are admitted to the hospital QAMC utilizes the hospitals on call physician to attend to your needs. The hospitalist is a primary care specialist who has focused their practice on inpatient care; QAMC has limited its practice to out-patient care. On discharge from the hospital please schedule a follow up visit within 7 days of discharge. It is best to contact the office within 24 hours of your release to allow enough time to schedule the follow up visit.

______________________________________________________________ DATE OF BIRTH___________________ PATEINT’S NAME

______________________________________________________________DATE SIGNED_____________________ PATIENT/RESPONSIBLE PARTY’S SIGNATURE


Quiroz Adult Medicine Clinic, P.A.

General Office Policies

_____FORMS: Our office charges a minimum of $25.00 for letters and forms from other facilities that need to be completed by the physician. These forms include but are not limited to U. S. Department of Labor and Medical Leave Act, school forms and any other employer forms. Please complete the demographic information before submitting to QAMC.

_____MEDICAL RECORDS RELEASED TO PATIENT: According to state guidelines, the minimum charge for the release of medical records to s patient is $25.00


Quiroz Adult Medicine clinic is committed to providing you and your family the highest quality health care. The policies are in place to help ensure that you receive quality care each time you interact with the staff and providers of the clinic.

Please review and initial each of the following policies and sign at the bottom of the page.

_____As the recipient of service, you are ultimately responsible to make payment for all services rendered to you. By agreeing to accept service, you also accept the responsibility to pay the balance, if any, left over after your insurance company has made payment. You will also be expected to accept full responsibility for all charges incurred for services on days that you cannot produce proof of insurance that certifies your eligibility with the plan.

_____Your insurance policy is a contract between you, your employer and the insurance company. The clinic’s relationship is with you not your insurance company. For this reason QAMC will not become involved in disputes between you and your insurer regarding deductibles, co payments, and covered charges, secondary

insurance, and “usual and customary” charges. As you medical provider, the clinic will only supply factual information to facilitate claim processing.

_____ Fees for services are due at the time of service is rendered. If there is a co payment or unpaid balance, the patient will be asked to render payment prior to the visit. Fees that are determined based on services will also be collected before the visit. For your convenience, QAMC accepts all forms of payment except American Express.

_____It is you responsibility to promptly remit to QAMC any payment made directly to you by your insurance company for services billed by QAMC. If you insurance company does not remit payment within 60 days of service the balance for service will be transferred to you and therefore be due by you, the patient.

______________________________________________________________ DATE OF BIRTH___________________ PATEINT’S NAME


Quiroz Adult Medicine Clinic, P.A.

General Office Policies

_____Once your insurance has reimbursed QAMC we will mail a paper statement of your responsibility. The bill is payable upon receipt. If the bill is not paid in full within 90 days and you have not contacted QAMC regarding payment, your account will be considered delinquent. As a last resort we may turn the account over to a collection agency.

_____At Quiroz Adult Medicine Clinic, we understand that financial problems may affect timely payment for services rendered. We encourage you to communicate any such problems to the staff, so we may assist you in keeping your account in good standing.


__________________________________________________________ DATE OF BIRTH: _______________________ PATIENT’S NAME


Authorization to Release Information

It is the physician’s responsibility to ensure that the physician – patient is confidential. The privacy Statement of Quiroz Adult Medicine Clinic, PA is the basis for how we treat your Protected Health Information (PHI).

Please review and initial each of the following policies and sign at the bottom of the page.

_____I authorize QAMC to release all medical information (including but not limited to: information on psychiatric conditions; sickle – cell anemia; alcohol and drug abuse; and HIV or communicable disease) requested by my health insurance carrier, Medicare, or any other third party payers.

_____I authorize QAMC to relapse and receive all medical information to and from my specialty physicians. _____I authorize QAMC to contact my insurance company or health plan administrator to obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance e company or health plan administrator to release such information to Quiroz Adult Medicine Clinic, P.A.

By signing the form below I authorize QAMC to disclose the protected health information as described below. The protected health information in my medical records may be released and/or discussed with the following persons (any records excluded from this release will be noted: Exclusions, if any:


Quiroz Adult Medicine Clinic, P.A.

Preventive Care Visits

In an effort to best serve you, the following is an explanation of preventive care visits; what they entail, and how they are useful in helping you attain and maintain a high level of health. The preventive exam is also known as a “physical”. Some insurance companies distinguish the physical exam from the well-woman exam, while others do not.

The preventive care visit or physical is a healthy visit. It is a time for you to come to the doctor to:

-review you current health status;

-discuss strategies to screen for certain health problems that may be silent or underlying; -recommend strategies to improve your current health;

-discuss methods to prevent future injury or illness.

Patients will often attend this visit with a list of concerns: various symptoms that have become bothersome or worrisome. In order to provide you with the best care possible, it is impractical to try to address all of the

preventive needs and these concerns at the same visit. Additionally most insurance companies will not cover a preventive visit which is defined a “well” visit, on the same day as a “sick” visit because they are by definition mutually exclusive. If at the time of the appointment the provider finds you unwell the providers will address the illness and reschedule the preventive exam.

As stated in the financial policy, QAMC will provide the insurance company with information that is factual. If the visit was a preventive visit, the clinic will bill it as such. If concerns regarding symptoms that are possibly an illness are addressed, the office will bill for a routine or sick visit. It is your responsibility to understand your insurance company’s policy regarding payment for the well visit as opposed to the sick visit.

______________________________________________________________DATE OF BIRTH: ____________________________ PATIENT’S NAME


Quiroz Adult Medicine Clinic, P.A.

No – Show Policy

Thank you for the confidence you have placed in Quiroz Adult Medicine Clinic, P.A. for the care of you r medical needs. The providers will prescribe an individual plan of care for your condition. This treatment plan will require commitments from both yourself and your provider.

Once this treatment plan is agreed to, the provider will need to monitor your progress and may require you to schedule regular clinical visits. In order to ensure the availability of appointments for those who require medical services, the clinic has established a “no-show” policy to protect the time of both yourself and other paitients at QAMC.

A “No-Show” appointment occurs when you do not show up for a schedule appointment, arrive after the next appointment has already begun, or you cancel your appointment with less than a business days notice. Monitoring you r condition is very important to the successful outcome of your care. It is for this reason that if you fail to show up to the clinic at your appointed time QAMC will charge a $25 fee for routine office visits and $50 for preventative care or physical exam appointments that are not kept.

If this problem persists, you may be discharged from the practice.

We ask that if you are unable to make your scheduled appointment, you please call the office at least 24 hours in advance. The staff will make every effort to reschedule your appointment at a time that is convenient for both you and the provider based on the urgency of the appointment.

______________________________________________________________DATE OF BIRTH: ____________________________ PATIENT’S NAME


Quiroz Adult Medicine Clinic, P.A.

Telephone Notification of Test Results

Please note that in the event of an abnormal test results, a message will be left on your answering machine instructing you to contact the office if you can not be reached. The nature of the test results will not be left on an answering machine or with anyone other than the patient.

Please initial ONE of the following regarding your preference concerning “normal” test results:

____ I authorize the staff at QAMC to leave a message that test results are “normal” on the answering machine or with whoever answers the phone at the number listed below.

Phone number: ____________________________________________________

____ I prefer to have the staff at QAMC leave a message for me personally to call the office regarding ALL lab results. In this case, a message ill simply request the patient to call the clinic regarding test results.

*Please note, normal mammogram results are sent by mail to the patient by the radiologist and are not routinely called.

With the exception of mammogram results, if you have not received a call from our office within three (3) business days of the test date, please contact our office.

______________________________________________________________DATE OF BIRTH: ____________________________ PATIENT’S NAME





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