OIMA Patient Packet

Insurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee.

It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals.

Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided.

Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card).

Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice.

Insurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee.

It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals.

Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided.

Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card).

Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice.

Appointments: Patients arriving more than 10 minutes after their appointment time will be asked to reschedule. We require 24 hour advanced notice of cancellation. A $45.00 fee will be applied to your account for short-notice cancellations or missed appointments. A second offense will result in a $90 fee. Patients who miss several appointments without calling may be discharged from our practice.

Annual Exam: Ocotillo Internal Medicine provides comprehensive medical care. As such, an annual appointment is required yearly of every patient. A new patient appointment (initial visit) is considered an annual appointment.

Annual exams at OIMA consist of the preventive portion as well as the assessment or management of specific symptoms or problems, acute and/or chronic. Insurance companies require all services to be itemized and coded appropriately. These codes are standardized and follow commercial insurance and Medicare guidelines. In order to provide you with the optimal medical care and for your convenience we provide these services in one visit. Please understand that because our annual appointments cover both types of services, some fees may be subject to your plan’s co-pay, deductible or coinsurance and it will be your obligation to pay those fees for which OIMA is contractually obligated to collect. If the preventative code is not covered, per your insurance, our office will charge a $65 fee.

Chronic Care Management Services: As part of an ongoing effort to enhance care coordination we are pleased to offer chronic care management services which will help better coordinate your care. Care coordination consists of non-face-to-face care services which Ocotillo will furnish to assist in your care among your different care provider and help you better manage your care. There will no out of pocket cost for this service.

By signing this agreement, you consent to have Ocotillo Internal Medicine Associates bill your insurance monthly for Chronic Care Management services provided to you by providers at Ocotillo Internal Medicine Associates. Please direct questions to our billing office. You may revoke this consent anytime by written request. There will be no out- of-pocket charges for the patient.

BY SIGNING THIS FORM, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS FINANCIAL AGREEMENT.

No changes to this policy by the patient will be acknowledged. Questions may be directed to the billing office.

Ocotillo Internal Medicine
245 S. Dobson Rd.
Chandler, AZ 85224

Phone: 480-895-5870

Fax: 480-895-0573

I understand that the information used or disclosed may be subject to re-disclosure by the person receiving it and would the no longer be protected by federal privacy regulations.

I may revoke this uathorization by notification in writing of my desire to revoke it. However, I understand that any action taken in reliance on this authorization cannot be reversed, and my recovation will not affect those action. I understand that the provider to whom this authorization is furnished may not condition its treatment or me on whether or not I sign the authorization.

This authorization expires two (2) years from the date of execution.