First Name * Last Name * Phone Number * Email * Date of Birth * Gender * Select One Male Female Transgender Best Time to Call * Anytime Morning (9:00am - 11:59am) Afternoon (12:00pm - 3:59pm) Evening (4:00pm - 6:30pm) How soon do you need an appointment? * Same Day if available Next earliest day available Preferred Appointment Day*
Date Format: MM slash DD slash YYYY
Preferred Appt Time * Morning (9:00am - 11:59am) Afternoon (1:00pm - 3:59pm) Evening (4:00pm - 8:00pm) Who is this appointment for? * Has the patient been to this practice before? * What type of appointment does the patient need? * Do you have insurance? Select one of the options below: *
Please select an option below if you are interested in learning more about MNsure (State Health Insurance Marketplace)
MNsure is Minnesota's health insurance marketplace where individuals and families can shop, compare and choose health insurance coverage that meets their needs.
MNsure is the only place you can apply for financial help to lower the cost of your monthly insurance premium and out-of-pocket costs. Most Minnesotans who enroll through MNsure qualify for financial help. https://www.mnsure.org/new-customers/whatis-mnsure/index.jsp
Medication List Medication Name | Dose | Frequency | Reason for taking the med
Example: Tylenol | 325mg | twice a day | for back pain
What else would you like your health care provider to know about your appointment? * Release of Billing Information
I hereby authorize the Brij Health, to release by electronic means or otherwise any medical and/or billing information concerning my care, including copies of my medical records to the following:
Any person or entity responsible for payment for the medical services rendered to me at the Facility, including third party payors, self-insurers, worker’s compensation carriers and government agencies or any person or entity acting as the agent or contractor of such party responsible for payment, in connection with obtaining payment for the medical services rendered to me at the Hospital by employees of the Facility or any person providing services at the Facility.
Federal, State or other governmental or quasi-governmental agencies or such other parties required by law for reporting purposes or for purposes of determining eligibility in government sponsored benefit programs.
Any person or entity participating in quality studies, utilization review or similar studies of the care rendered by the Facility and /or its physicians.
Any health professionals involved in my care for the purpose of facilitating the continuity of my medical care.
To persons authorized by the Facility in connection with the performance of supervised research in compliance with the rules and procedures of the Facility. I also understand that an authorized researcher may contact me at some future date.
I acknowledge that the above authorization has no expiration date and is valid to authorize the release of medical records and billing information at any time a valid request is received.
This includes information relative to alcohol abuse, drug abuse, psychological or psychiatric conditions and Acquired Immune Deficiency Syndrome (AIDS).
ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize my Medicare and/or medical insurance benefits to be paid directly to Brij Health, separately from other Facility or professional bills. I understand that I am financially responsible for non-covered services as well as any deductibles, coinsurance or amounts in excess of insurance benefits. If coverage is denied, I give my express consent to appeal to the insurance on my behalf.
FINANCIAL RESPONSIBILITY: In consideration of services rendered or to be rendered to the patient designated herein at my request for this occasion of service, I guarantee and agree to pay charges for those services rendered including any amount not paid in my insurance plan, Medicare, health service plan or health maintenance organization. Members of health maintenance organizations (and preferred provider organizations) are generally required to comply with certain policies and procedures requiring use of participating providers and compliance with plan requirements for primary referral, emergency admission, pre-certification and utilization review. These are conditions to payment of benefits by the health maintenance organizations (and preferred provider organizations). Brij Health, may not participate with your health care coverage plan and their charges may not be covered.
By signing the financial responsibility statement, the patient and guarantor(s) acknowledge and agree they are responsible for payment of billed charges rendered in any case in which payment may be denied by the health maintenance organization (or preferred provider organization) because of a failure to comply with such coverage requirements or for any other reason.
A copy of this form shall have the same force and effect as the original.
I acknowledge that I have read and understand its contents fully. The undersigned is the patient, the patient’s legal representative or is authorized by the patient to execute this form and accepts its terms.
Insurance: Brij Health participates with most insurance plans and Medicare. As a courtesy to our patients we will file all primary and secondary insurances. You will be asked to complete a registration form, provide your current insurance card and a photo ID during each visit. You are responsible for all co-insurance, deductible and non-covered services not paid by your insurance company. A statement will be sent after your insurance company has processed your claim. Payments are due upon receipt of statement.
Dispute of Insurance payment: If you feel that your insurance company has processed your claim incorrectly, it is the patient's responsibility to contact the insurance company to resolve the dispute. Diagnosis will not be modified to fit your insurance benefit.
No Insurance/Self pay: If you do not have insurance or cannot provide an insurance card at time of service, a $100.00 deposit will be required for office visits and a $50.00 deposit will be required for imaging/lab-only visits.
Co-pays: In accordance with the guidelines established by your insurance company, SCMG is required to collect all co-pays at the time of service. Brij Health reserves the right to reschedule your appointment if you do not have your co-pay.
Payment Options: We accept cash, checks, MasterCard, Visa, and Discover. If needed, reception is able to assist you in locating the nearest ATM.
Select Services: Brij Health reserve the right to request a deposit and/or prepayment for select services.
Past Due Accounts: We consider patient accounts to be past due after 30 days. Please contact the business office if you need to set up an appropriate payment plan. Failure to pay account balance will result in your balance being transferred to a collection agency. Accounts in collections cannot make further appointments until the balance is paid in full.
Service Charge for Returned Checks: A service charge of $30.00 will be added to your account for any check that is returned to us from your bank.
Cancellation of Appointment: If you are unable to keep your scheduled appointment, please call our office as soon as possible to cancel or reschedule. If you miss two scheduled appointments, Brij Health reserves the right to require a $50.00 deposit prior to scheduling the next appointment. If you miss three scheduled appointments, we reserve the right to terminate your care.
Charity Care: It is expected that patients pay for their health care services. Brij Health will evaluate the needs of patients that have indicated a possible financial hardship. Charity Care reductions will be applied to any future visits that the patient might incur, not for any existing balances. A written application must be filled out and must include a copy of the most recent Federal and State Income Tax returns, payroll check stubs from the last three months, Medical assistance denial or approval of spend down with a letter dated no older than 90 days, and possibly a loan denial if the account balance is over $500.00. Please contact the Business Office for an application. Once we have received a completed application, the billing office staff and/or the patient's physician will determine the amount of the Charity Care reduction.
Minor/Dependent of Divorced or Separated parents: Both parents are financially responsible for all services rendered to minor/dependent children regardless of who is the statement recipient on the account.
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