ATTENTION PLEASE: YOU CANNOT SIGN IN ONLINE BEFORE 8AM OR AFTER 4PM WEEKDAYS, OR BEFORE 9AM OR AFTER 3 PM ON WEEKENDS! Please choose the location you will be going to. PLEASE NOTE: You must arrive within 30 minutes of your on-line check in time to keep your on-line check in time slot. If you show up after the 30 minutes time period you will be given the arrival time of walking into the clinic. Online check in time that...
ATTENTION PLEASE: YOU CANNOT SIGN IN ONLINE BEFORE 8AM OR AFTER 5PM WEEKDAYS, OR BEFORE 9AM OR AFTER 4 PM ON WEEKENDS! First Name Last Name Birth Date Phone Number Reason for Visit Has your address changed since last visit? Yes No If a balance is owed at either clinic, you will be notified when you arrive and will be expected to pay before you are seen. Deductibles and co-pays are due at time of treatment.
HILLTOP MEDICAL CLINIC1093 HILLTOP DRIVE, REDDING, CA 96003HILLTOP MEDICAL CLINIC WEST2123 EUREKA WAY, REDDING, CA 96001 DEAR NEW MEDICARE PATIENTS - PLEASE READ AND SIGN FOR MEDICARE “SIGNATURE OF FILE” REQUIREMENTS. DEAR ESTABLISHED MEDICARE PATIENTS - PER MEDICARE, WE ARE REQUIRED TO NOW USE THIS UPDATED FORMAT FOR OUR “SIGNATURE ON FILE” REQUIREMENT. THEREFORE, WE MUST HAVE EACH ESTABLISHED MEDICARE PATIENT SIGN ONE TO RETAIN ON FILE. THANK YOU VERY MUCH IN ADVANCE FOR YOUR COOPERATION REGARDING THIS REQUIREMENT. I...
1. Hilltop Medical Clinic/Hilltop Medical Clinic West is a NON-Participating Provider for Medicare.We have a provider number with Medicare for them to process the claim and pay directly to you. 2. We are payment at the time of service. We do NOT Accept Assignment (Medicare payment) on Medicare claims. 3. Medicare will consider reimbursement on the Physician, Xray and some injection charges.We are notifying you that Medicare will NOT reimburse you for the following services (nor will Hilltop Medical Clinic/ Hilltop Medical Clinic...
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Hilltop Medical / Hilltop Medical Clinic West to furnish my insurance company(ies), and/or their Attorney or an Industrial Related Injury insurance company, and/or their Attorney or collection agency, with any and all information which said parties my request to be provided with, concerning my office visits here. WAIVER OF CONFIDENTIALITY: If the account is submitted to an attorney or collection agency, goes to court or is reported to a credit reporting agency, the...
IMPORTANT BILLING NOTICE ♦♦♦ MUST READ AND SIGN RE: PPO & OTHER INSURANCE BILLING HILLTOP MEDICAL CLINIC/ HILLTOP MEDICAL CLINIC WEST offers PPO & other insurance billing as a courtesy to our patients. Our policy is as follows: 1. We will bill your insurance, but expect payment at the time of service if your annual deductible has NOT been met. 2. If NO deductible or it has been met - You will be required to pay your copayment amount at...
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Hilltop Medical Clinic West ♦ 2123 Eureka Way ♦ Redding, Ca 96001 ♦ (530)246-4629 I understand that under the Health Insurance Portability and Accountability Act of 1996, (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used for the following: ● To conduct, plan, and direct my treatment and follow-up among multiple healthcare providers who may be involved in that...
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