Dr. Mark Richey offers general medical, and specialty gynecological and obstetrical services for patients. We require certain information from each patient in order to begin your care. The additionally provided forms need to be completed in order for us to get you started and maintain your records as our patient.
- Patient Registration Form & Patient Agreement **
- Healthcare Portability & Accountability Act (HIPAA) Notice of Privacy Practices Acknowledgement**
- State or Federally Issued Identification Card (Please provide at each visit)
- Copy of Insurance Identification Card (annually or as insurance coverage changes)
- Medical Genetics Questionnaire (for new OB patients) *
- New Patient & Pre-Physical Exam Questionnaires (for all new patients) *
- Choice of Laboratory (if you/your insurance prefers a specific lab other than Quest Lab)
- Review of Systems (Clinical consideration worksheet you may complete at each visit)
** To be completed every three (3) years unless the forms change with new requirements
* To be completed by new patients
PAYMENT FOR SERVICES
Each patient is responsible for the payment of their medical services. We gladly bill healthcare payers as a courtesy to our patients and need a copy of your current insurance ID card. If your healthcare insurance payer does not cover particular medical services, you are welcome to make self pay arrangements at the usual and customary pricing.
DISCOUNTS FOR IMMEDIATE PAYMENT
If you would like to pay at the time service or prior to services being rendered, we can offer you a 10% discount. Due to Dr. Richey’s participation in federally funded programs, discounts after the time of services cannot be offered. We will not post duplicative discounts for both patient payments and insurance contract discounts.
NO SHOW FEES
If you are not able to keep your scheduled appointment you need to contact our front desk one (1) business day in advance. Failure to notify the front desk and confirm your cancellation with staff may result in a no show fee. No show fees are required to be paid prior to scheduling future appointments.
ALASKA MEDICAID RECIPIENTS
Only a limited number of new Medicaid patients are accepted each month. Patients seen with Medicaid coverage are required to provide proof of eligibility and co-pays at the time of service. If a patient is admitted for service on the premise that they do not have Medicaid and later obtain retroactive primary or secondary coverage, the patient may be liable to pay for all services provided prior to providing proof of current or prospective Medicaid and meeting the practices’ service limits.
All patients that fail to attend scheduled appointments and are charges a “no-show” fee are responsible to pay the no-show fee prior to scheduling additional appointments. Medicaid does not cover “no-show” fees, as is specifically described in the Alaska Administrative Code (AAC) 7 AAC 105.110. Noncovered services (8) for missed appointments; however, the provider may charge the recipient.
REFERRALS FOR PERINATOLOGY MEDICAL SERVICES
When a patient has a need to see a specialist for a service that medically justifies it, Dr. Mark E. Richey will use his best professional opinion and expertise to send you to the most qualified practitioner he is aware of to meet your medical need. Dr. Richey provides specialty care in gynecology & obstetrics. If a patient may benefit from the services of a board certified perinatologist, patients may be referred to Alaska Perinatology Associates for those medical needs associated with pregnancy. All patients have the right to choose their practitioners and patient requests will be observed. Please consult Dr. Richey on your preferences at the time of referral.
REFERRALS FOR OTHER MEDICAL SERVICES
Certain practitioner services may need a physician referral for healthcare payer reimbursement. If you believe you would benefit from a referral to a practitioner that requires a physician referral, please consult with Dr. Richey about this at the time of your visit.
Many healthcare payers, including federally funded payers may require that we have written authorization and/or consent to provide sterilization services. We may need your cooperation to complete forms for these services.
QUALITY ASSURANCE & RESOLUTION
Should you have a concern or experience a situation that requires the direct attention of Dr. Richey, please contact our practice either by phone or in writing. Our staff will interact with you and Dr. Richey to reach a resolution of any identified situation where our quality of service has been compromised or may need to be reviewed. We use such situations to alert us to improvements we can make to better serve all our patients.
ASSIGNMENT OF BENEFITS
My signature on this agreement is my written authorization for Mark Richey, MD, PC to submit claims to my identified healthcare payer and receive direct payment for deposit of funds paid on my behalf under my current healthcare coverage. This is a direct assignment of my rights and benefits under my current insurance policy for payment of my medical services. I also authorize the release of any information pertinent to my care to my insurance, adjuster or attorney involved in the care and payment of my medical services. This provider has my permission to submit claims or complaints on my behalf to the State of Alaska Division of Insurance.
Our practice uses Sage Consulting Incorporated, a professional billing service, to process your claims to healthcare payers and to arrange payment of patient balances. We have all the required agreements in place to insure that your protected health information is safe and remains confidential. If you have inquiries about your healthcare claims, monthly statements or if you have additional billing information, you may reach our billing agent at:
FOR BILLING INQUIRES AND MAKING PAYMENTS
CALL OR FAX
(907) 272-4443 Phone
(907) 272-2262 Fax
PAYMENT & PAYMENT PLANS
All patients are responsible for any and all charges not paid for or discounted under contract by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, Worker’s Compensations, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to reimbursing Mark Richey MD, PC, in a timely manner for the services we provide to you, our valued patient.
We accept cash, checks, and credit or debit cards (VISA, Mastercard, American Express, Discover Card). We offer pre-payment discounts and recurring monthly payment arrangements for patient balances. We are willing to make reasonable payment arrangements to keep your account current. Please contact our Billing Office at (907) 272-4443.
We offer patients the opportunity to make payments on balances over the period of three (3) months following the issuance of the first patient statement. Exceptions can be made to extend the repayment period upon review and approval. Failure to pay on a patient account as agreed is a basis for an account to be assigned to collections for bad debt recovery.
INTEREST CHARGES ON PATIENT BALANCES
Our practice charges interest on unpaid account balances. Following payment/denial reply on your claims from your healthcare insurance payer, we will bill you for the balance of the unpaid portion of your visit. Interest will begin to accrue on unpaid balance 30 days AFTER we have sent you the 1st statement of the amount that is due. We charge interest based upon the percentages approved by Alaska Statute. You may contact our billing agent for the current rate of interest.
COLLECTION OF PAST DUE ACCOUNTS
We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail or if a patient payment agreement cannot be honored and we are not communicated with to resolve account balances, we may be forced to use the services of a professional collection agency. Once an account is placed with our contracted collection agency, under our contract with them, we cannot take the account back. Please let us know when or if your patient contact information changes so that we can always reach you to discuss any past due accounts.
RELEASE OF PATIENT CLINICAL RECORDS
All release of medical records requires a signed and dated Release of Information (ROI) form with a current date (within prior 90 days). Please allow two (2) business days to process records requests.
PATIENT STATEMENT OF AGREEMENT
This patient agreement and the terms within it are effective for three (3) years from the date of my signature or until the agreement is revised.
My signature below signifies that I have read and understand this patient agreement for Mark Richey, MD, PC to provide me medical services. I understand and agree to the terms in this patient agreement and intend on complying with them to the best of my ability. I also understand that if I fail to follow the terms of this agreement, I could be cancelled from future services.