Authorization of payment to NorthStar Surgery Specialists
I, the undersigned, authorize payment of medical benefits to Northstar Surgery Specialists, P.A. for any services furnished to me by the physician.
I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided to me.
This information will be used for the purpose of evaluating and administering claims of benefits.
Acknowledgment of privacy practices
I have reviewed the "Notice of Privacy Practices" of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice's legal duties with respect to my PHI.
I understand that I am entitled to receive a copy of this information upon request.
Cancellation policy
New patients who no-show to a scheduled appointment are subject to a $50 no-show fee.
If a new patient cancels within 24 hours and does not reschedule, a $50 cancellation fee will be charged. However, if a new patient calls within 24 hours to reschedule to a new appointment date, the cancellation fee will be waived. Please note: new patients are allowed up to two reschedules without penalty. If a new patient reschedules for the third time, a $50 fee will be charged (three reschedules will be considered a forfeited appointment slot).
Established and post-operative patients are subject to a $50 cancellation, reschedule, or no-show fee if less than 24 hours notice is given.
A 7-day notice is required to cancel or reschedule any surgery or office procedure. If less than 7 days notice is given, a $500 cancellation fee will apply.
Release of medical records
I am requesting that the medical information be transferred to Vineet Choudhry MD.
I understand that the information in my or my child's health record may include information relating to STD, AIDS, or HIV.
It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.