PATIENT RESOURCES

Walter Alain Thomas, M.D.

Specializing in Sports Medicine and General Orthopaedic Surgery
American Board of Orthopaedic Surgery
Qualified Medical Examiner

New Patient Forms

PATIENT INFORMATION FOR MEDICAL RECORDS



IF PATIENT IS A MINOR, PLEASE COMPLETE USING PARENT INFORMATION:



INSURANCE INFORMATION


(If Yes please ask for work comp packet)

PRIMARY INSURANCE



NEW PATIENT QUESTIONNAIRE



Walter Alain Thomas, M.D.

Specializing in Sports Medicine and General Orthopaedic Surgery
American Board of Orthopaedic Surgery
Qualified Medical Examiner


Receipt of Notice of Privacy Practices
Written Acknowledgement Form


By signing this document, I acknowledge that I have read the "Notice of Privacy Practices" for Walter A. Thomas M.D. I also understand that if I wish to be given a copy of "these" practices, I will be given such.



Walter Alain Thomas, M.D.

Specializing in Sports Medicine and General Orthopaedic Surgery
American Board of Orthopaedic Surgery
Qualified Medical Examiner

Permission to correspond via Email

Dr. Walter A. Thomas and Staff may decide to use email to facilitate and billing.

Risk of using email

I want to use email to communicate to the physicians and staff about my/the patient’s personal health care and billing. I understand that both the Providers and staff will use reasonable means to protect the security and confidentiality of email information sent and received. I understand that there are known and unknown risks that may affect the privacy of my personal health care information when using email to communicate. I acknowledge that those risks include, but are not limited, to:

  • Email can be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without my knowledge or agreement.
  • Email may be sent to the wrong address by any sender or receiver and is not guaranteed.
  • Copies of email may exist even after the sender or the receiver has deleted his or her copy.
  • Email service providers have a right to archive and inspect emails sent through their systems.
  • Email can be intercepted, altered, forwarded, or used without detection or authorization.
  • Email can spread computer viruses.

Conditions for the use of email

I agree that I must not use email for medical emergencies or to send time sensitive information to my/the patient's Providers. I understand and agree that it is my responsibility to follow up with the Providers or staff, if I have not received a response to my email within a reasonable time period. I agree that the content of my email messages should state my question or concern briefly and clearly and include the subject of the message in the subject line, and clear patient identification including patient name and contact information in the body of the message. I agree it is my responsibility to inform the Providers and/or staff of any changes to my email address. I agree that, if I want to withdraw my consent to use email communications about my/the patient’s healthcare, it is my responsibility to inform my/the patient’s Providers or the staff member only by email or written communication.

Understanding the use of email

I give permission to the Dr. Walter A. Thomas and staff to send me email messages that include my/the patient’s personal health care information and understand that my email messages may be included in my/the patient’s medical record. I have read and understand the risks of using email as stated above and agree that email messages may include protected health information about me/the patient, whenever necessary.

In addition Dr. Walter A. Thomas and staff may utilize text messages to confirm appointment times, and inform you of missed appointments. If you would like to receive appointment reminders via text please provide us with a personal cell phone number. Information via text message will only include appointment times and missed appointments. Text messages will not include personal healthcare information or billing information.



Walter Alain Thomas, M.D.

Specializing in Sports Medicine and General Orthopaedic Surgery
American Board of Orthopaedic Surgery
Qualified Medical Examiner

Patient Payment Policy

Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment and care.

For your convenience, we have answered a variety of commonly-asked financial policy questions below. If you need further information about any of these policies, please ask to speak with a Billing Specialist or the Practice Manager.

How May I Pay?
We accept payment by cash, check, VISA, Mastercard, HRA, HSA, debit, Discover and AMEX.

Which Plans Do You Contract With?
All major carriers such as Blue Cross, Blue Shield, Aetna, Cigna, Healthnet, United Healthcare, Medicare. Many other smaller plans fall under the large carriers. Please call your carrier or our office to confirm.

What Is My Financial Responsibility for Services?
Your financial responsibility depends on a variety of factors, explained below.

Patient deductibles and co-pays will not be adjusted and/or written off. It is a violation of the provider’s contract with the insurance company. The outcome for the provider could be the loss of his/her contract and 100% non-payment of services to which he/she could not recoup from the patient. Thank you for your understanding of this policy.


IF YOU HAVE: PPO plans with which we have a contract

YOU ARE RESPONSIBLE FOR: If the services you receive are covered by the plan: All applicable copays and deductibles are requested at the time of the office visit. If the services you receive are not covered by the plan: Payment in full is requested at the time of the visit.

OUR STAFF WILL: Call your insurance company ahead of time to determine copays, deductibles, and non-covered services for you. File an insurance claim on your behalf.


IF YOU HAVE: Point of Service Plan or Out Of Network PPO

YOU ARE RESPONSIBLE FOR: Payment of the patient responsibility—deductible, copay, non-covered services—at the time of the visit.

OUR STAFF WILL: Call your insurance company ahead of time to determine out of network benefits, copays, deductibles, and non-covered services. File an insurance claim on your behalf.


IF YOU HAVE: Worker’s Compensation

YOU ARE RESPONSIBLE FOR: If we have verified the claim with your carrier - No payment is necessary at the time of the visit. If we are not able to verify your claim - Payment in full is requested at the time of the visit.

OUR STAFF WILL: Call your carrier ahead of time to verify the accident date, claim number, primary care physician, employer information, and referral procedures.


IF YOU HAVE: Worker’s Compensation (Out of State)

YOU ARE RESPONSIBLE FOR: Payment in full is requested at the time of the visit.

OUR STAFF WILL: Provide you a receipt so you can file the claim with your carrier.


IF YOU HAVE: Occupational Injury

YOU ARE RESPONSIBLE FOR: Payment in full is requested at the time of the visit.

OUR STAFF WILL: Provide you a receipt so you can file the claim with your carrier.


IF YOU HAVE: No Insurance

YOU ARE RESPONSIBLE FOR: Payment in full at the time of the visit.

OUR STAFF WILL: Work with you to settle your account. Please ask to speak with our staff if you need assistance.


Surgery
If your physician recommends surgery, you will be escorted to his Surgery Coordinator. Who will answer specific questions about the surgery scheduling process, discuss the paperwork and tests involved, and complete all pre- certification/authorization if your insurance company requires it.

The Surgery Coordinator will request a pre-surgical deposit, the amount of which depends on your coverage and deductible amount. A cost estimate which shows your financial responsibility, based on the benefit levels and coverage of your insurance plan, will be explained by the Surgery Coordinator.

What if My Child Needs to See the Physician?
A parent or legal guardian, 18 years of age or older, must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment of the account, according to the policy outlined on the previous pages.

I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.

I authorize my insurance benefits be paid directly to Walter A. Thomas, MD.

I authorize Walter A. Thomas, MD to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.


Please note that by submitting this form, you are still required to physically sign and date a printed copy of this form at the office location for your patient registration to become valid. Completing this online form will send a copy directly to the doctor and you will also be provided with a download link of the completed form in PDF format.