Insurance Health Information (Primary Carrier) *A copy of your insurance card is required.

Family History: (Please check pertinent family history)

Screening History

•  I have never smoked (non-smoker).  
•  I am a former smoker and smoke per day.  
•  I currently smoke cigarettes or cigars per day.  
•  I currently use e-cigarettes a day.  
•  I currently vape x’s per day.  
•  I use caffeine a day.  
•  I drink alcoholic beverages per week.  
•  I drink more than 10 alcoholic beverages a week.  
•  I exercise times a week.  
•  I do not exercise.  

Please List All Medications and Dosage You Are Currently Taking.

Hormone Replacement History

Hormone Replacement Fee Acknowledgement and Insurance Disclaimer

Bio-Identical hormone replacement is a unique practice and is considered a form of alternative medicine. Although many board-certified medical providers offer bio-identical hormone replacement therapy to their patients, in most cases, insurance companies do not recognize it as a medical necessity.

BioEnve is not contracted with any insurance company. BioEnve will not contact any insurance company directly or indirectly to seek prior-authorization, benefit details or reimbursement for the bio-identical pellets and/or supplements.

Payment will be required at the time of service. Upon request, we will gladly provide a detailed receipt if you wish to seek insurance reimbursement directly. WE WILL NOT, however, communicate in any way with insurance companies.

This form and payment will serve as evidence of your out-of-pocket payment made, and your decision to proceed with the bio-identical hormone replacement treatment and/or to purchase recommended supplements.

For Health Savings account holders, you may choose to pay for bio-identical pellets and/or supplements with your health savings credit/debit card. Some of these accounts require that you pay in full ahead of time, and request reimbursement later with a receipt and letter. However, please be aware that your insurance company HSA account may seek reimbursement from you if it is determined not to be an eligible benefit through your plan.

By signing my name below, I certify that I have read the above information. My signature also certifies my understanding of, and agreement with, the above terms. I also understand that I am responsible for all charges with BioEnve.

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Servies. www.hhs.gov

We have adopted the following polices:

1. Patient information will be kept confidential except as it is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, ect. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the provider.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.

9. You have the right to request restrictions in the use of our protected health information and to request change in certain policies used within the office concerning you PHI. However, we are not obligated to alter internal policies to conform to your request.

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

I authorize my physician and his/her staff to communicate information regarding my appointment, medical results, and billing issues to:

  Spouse

  Other

  Other

  Other

Check In- Your time is important to us. The first step in keeping your appointment on time is being prepared. This includes filling out all required paperwork prior to your first appointment. It is extremely important that you provide each piece of information that is requested on both the Patient Information and Medical History Questionnaire. This will avoid delays in creating your chart and account at your visit. Please arrive at least 10 minutes prior to your scheduled time so that all information can be verified.

Missed Appointments, Late Cancellation, Late Arrivals, and Non-Compliance- We require a 24-hour advance notice, you must cancel or reschedule your appointment. We offer patient reminder calls, texts and/or emails prior to your appointment which will allow you to cancel or reschedule. However, it is ultimately your responsibility to keep track of your appointment whether you receive a reminder or not. Cancellations made with less than the required 24-hour advanced notice will be charged a $25 late cancellation no-show fee, and patients with multiple cancellations or missed appointments may be discarded from our practice.

*Please note that non-compliance with treatment plans including medication and/or lab work and abusive/inappropriate behavior towards staff and/or patients will result in immediate dismissal of your care from our practice.

Nurse Practitioners/ Physician Assistants- Dr. McCain has Nurse Practitioner(s) and/or Physician Assistant(s) to assist in the delivery of medical care. All medical providers are advanced practice providers who have completed a graduate level education and training in the diagnosis and management of medical conditions.

Forms of Payment- We accept payment in the form of cash, debit and/or credit cards. Checks are no longer accepted as a form of payment due to the high volume of returned checks. If an approval is given to you to pay by check, if the check is returned as non-sufficient or for any other reasons, you will be charged an additional $35 fee.

*Please note that there is a 3.5% service charge fee when paying by debit, credit or any Health Savings debit/credit card.

Collection Fees-All office visit charges are due at the time of service. This will include any co-pays or co-insurance amounts. If for some reason it is not collected at the time of service or if the insurance company does not pay the expected amount, a statement will be sent, and the balance will be due upon receipt of the statement. We will send a maximum of 3 statements, then your account will be turned over to a collection agency.

   
I have read, understand and agree to the above office and financial polices of Stefanie McCain, MD. I hereby attest that I have been given and agree to provide current demographic and insurance information and authorize release of information necessary to insurance filing by signing this statement. My signature below states my agreement and understanding of Stephanie McCain, MD’s office and financial policies and serves as a request and consent for treatment. I authorize and assign all benefits to be made directly to Stefanie McCain, MD.