Patient Update Form
This form is for established patients only. Please feel free to enter only identifying information, and information that has changed. If you have any additional questions or concerns, do not hesitate to contact us.
I want patients to be comfortable with my policies and style of practice before establishing care. Please carefully review our office policies below. If you have any questions regarding our policies, please do not hesitate to contact us.
It is your responsibility as a patient to know your insurance benefits.
We submit claims to your insurance company as a courtesy. However, if your insurance does not cover the visit for any reason, you will be responsible for the charges.
If you have an unmet deductible, $180 will be due at your first appointment. Once we bill your insurance and the claim is paid, your account will be adjusted accordingly. Depending on what your insurance covered, you will receive either a reimbursement or a bill for the remaining balance of the visit.
Private Practice Premium
We are the last remaining independent primary care private practice in Oakland!
Our patients support the added value of a private practice with an Annual Private Practice Premium fee of 99.00* which helps us provide services and benefits beyond what insurance covers. We have a risk-free approach which guarantees you'll see value with the Premium. Please see our website for details.
*Payment will be due at time of service billed annually one year after the previous payment. Payment in full is not a prerequisite for receiving medical care at our office. To understand your payment options please inquire.
Appointments must be cancelled or rescheduled at least 24 hours prior to the appointment time. If you miss your appointment or do not cancel or reschedule at least 24 hours in advance, you will be charged a $50 missed appointment fee.
Due to insurance restrictions, we are unable to see patients both for a preventive exam and to discuss a medical problem during one appointment. Sick visits and preventive visits (including PAP smears) must be held on separate calendar days.
If you have been in a car accident, we will be happy to see you but will not bill your medical insurance for these types of injuries. Full payment will be due at the time of your visit. We will provide you with an invoice that you may submit to the appropriate third party insurance company (i.e. car insurance) for reimbursement. This applies to motorcycle accidents as well.
We do not see worker's compensation injuries or fill out disability forms. FMLA and sick leave forms are filled out as long as the diagnosis is within my scope of practice.
Separate fees may apply if additional time is required to complete legal documents or extensive forms on your behalf.
Your Electronic Health Records are protected by law under the Health Insurance Portability and Accountability Act. Your records will never be released to any party without your written authorization, except in the cases of treatment, payment, or operations in accordance with the law.