Important Information on Office Visits

We no longer have contracts with the following insurance companies: Aetna, Blue Shield tandem plans/ Blue Shield Pers gold, GEHA, Cigna, United Healthcare, UMR, and EBMS. Our prices if paying in full are typically $150 for a new patient visit and $140 for an established patient (seen in office within 3 years) for a provider visit. Extensive circumstances may warrant an increase in charges. Some insurance companies allow you to recover a portion of the costs with a non-contracted provider visit.

Following the CDC guidelines, masks are still required in medical facilities. Please bring your own mask.

Telemedicine: For the protection of other patients who require in-person medical care, anyone with an infectious illness will first be directed to our telemedicine provider. For Telemed visits, you will be contacted by phone while waiting in the comfort and safety of your home.

Are you a New or Returning patient?

Required telemedicine, preferred Telemed or in-office visit?

Infectious Illness Screen (Thank you for being forthcoming)

Have you experienced the onset of these symptoms in the last 7 days?

1. Fever: . If yes, how high?

2. Runny nose, sore throat, cough:

Reason for your visit (required)

Please Use Legal Name

Last Name (required)

First Name (required)

Middle Initial (required)

Birth Date mm/dd/yyyy (required)

Social Security No ###-##-#### (required)

Primary Phone Number xxx-xxx-xxxx (required)

Cell Phone Number xxx-xxx-xxxx

Address (required)

City (required)

State (required)

Zip Code (required)

Sex: MaleFemale

Parent or Legal Guardian

Emergency Contact

E-maill Address

Method of Payment

Consent for Treatment

Medical care at Hilltop Medical Clinic requires a relationship between the Patient, the Providers, the Clinic Staff, the Clinic Managers, and the Clinic Owners. The relationship requires trust and mutual respect. In addition to the policies noted below, signing this form authorizes the medical providers at the Clinic, to take a history and perform a medical exam in order to diagnose and develop a treatment plan.

Scope of Treatment

・ Hilltop Medical Clinics provides urgent care services. This is different from a medical home or primary care provider, who is responsible for preventive care and management of chronic medical conditions. ・ We encourage all patients to have a primary care provider. ・ We recognize that that is not always possible, so patients use HTMC for their primary care services. Of course, we do not want your medical care interrupted, but you are responsible for keeping follow up appointments and preventive care services. HTMC does not have a system to remind patients of appointments. Clinic Policies ・ Examination of sensitive or personal areas will be in the presence of a chaperon. A family member is not a legal chaperon. ・ HTMC and its providers will not prescribe medications for assisted suicide. This requires an ongoing relationship with a primary care provider or hospice provider. ・ HTMC does not provider medical marijuana prescriptions. ・ Prescriptions of controlled medications require a picture ID and fingerprint to be released to the patient. Prescriptions for patients under 18 must be released to the parent or legal guardian. ・ Aggressive behavior will not be tolerated and will result in an immediate dismissal from the practice. ・ Dismissal from the practice. An explanation or justifications is not required. We will notify you by registered mail and continue to provider medical care for 30 days. ・ HTMC is a nondiscriminatory environment, however, genetic and therefore racial and cultural differences are used to make medical decisions based on scientific studies that support this approach. ・ Animal bites are reported as required by law. ・ HTMC does not bill third party claims (motor vehicle accidents, injuries sustained while shopping, homeowners liability claims, etc.). Payment is expected at the time of service and a billing/receipt will be issued to you for billing purposes. ・ HTMC is not in network with HMO plans, United Healthcare, GEHA, UMR or Cigna, or Blue Shield PPO Tandem plans. ・ HTMC does not accept or bill ANY Medi-Cal, Medicaid or other state sponsored health plans. This applies nationwide. If you are covered by any of the above mentioned plans, and you choose to be seen in our office, by signing this form you are accepting financial liability for all services provided. Patient ・ You have the right to obtain a second opinion, refuse treatment, or change your mind without judgment or pressure. ・ You are encouraged and requested to ask questions in order to understand the diagnosis and treatment options for your medical problem. ・ Consent forms for minor procedures and injections are not required for treatment. Receiving treatment is acknowledgment that you understood the risks and benefits and agreed to proceed. ・ Results of sensitive tests cannot be sent by text, e-mail or answering phones. You must call in for the results. Refunds ・Our office will automatically generate a refund for $75.00 or more when due, once all visits are processed and payment received from insurance. If you are due a refund less than $75.00, we will leave it on your account for future use. You can call and request your refund be issued if you prefer. Provider ・ Providers frequently have to ask sensitive, personal questions to diagnose medical conditions. Parents should excuse themselves from the exam room, if they do not want to hear the answers. ・ Providers are not obligated to provide medical care or services that they feel are not warranted. ・ Providers are required by law to report episodes of complete loss of consciousness to the health department. ・ Providers are required to report any suspected episode of child or spousal abuse to the police. Medical Records ・ Medical Records will be maintained in electronic format for the duration of time required by California State law. ・ You may obtain a copy of your records at any time in digital format or as a printed copy. Charges apply for copies of your medical records. ・ Employees at HTMC may contact and disclose medical information to the persons listed as guardians and emergency contacts, without additional notification or permission from you, the patient. Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

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Billing Policy

HILLTOP MEDICAL CLINIC offers primary and some secondary insurance billing as a courtesy to our patients.

Our policies are as follows:

We will bill your primary insurance and some secondary insurance companies.
Services performed outside of HMC will bill you separately.
HMC does not bill third party claims (motor vehicle accidents, injuries sustained while shopping, homeowners liability claims, etc.). Payment is expected at the time of service and a billing/receipt will be issued to you for billing purposes.
Insurance co-payments and deductible amounts are required at the time of service.
Billing insurance does not relieve you of the responsibility for your bill.
You will receive monthly statements so you will be aware of any outstanding balance on your account.
We allow 60 days from the date of service for ALL insurances to respond. Thereafter, you will be expected to pay the balance.
Patients discovered to not have insurance or those with deductibles are expected to pay the balance immediately. You cannot be seen at the Clinic until the debt is paid.
Hilltop Medical Clinic charges a $20.00 fee for any returned check or declined POST DATED credit card.
Our office cannot follow up on all delinquent insurance claims. It is recommended that YOU please call your insurance company and check on the status of the claim within 30-45 days.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Hilltop Medical Clinic 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 may request or 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 fact that you received treatment here may become a matter of public record.
ASSIGNMENT OF BENEFITS: I hereby assign Hilltop Medical Clinic all money to which I am entitled for medical and/or surgical expense related to the services reported herein, but not to exceed my indebtedness to Hilltop Medical Clinic. It is understood that any money received from the insurance company(ies) over and above my debt will be refunded to me, or back to my insurance company, when my bill is paid in full. I understand that I am financially responsible to Hilltop Medical Clinic for charges not covered by this assignment.

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Primary Insurance

Second Insurance

HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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 treatment, directly and indirectly.

● To obtain payment from third-party payers, including use as a means by which an insurance or other payer can verify that services billed were actually provided.

● To conduct normal healthcare operations such as quality assessments and reviewing physician competence for physician certifications.

I have been provided with Hilltop Medical Clinic’s Notice of Privacy Practices, which document contains a more complete description of the uses and disclosures of my health information. I understand that Hilltop Medical Clinic has the right to change its Notice of Privacy Practices from time to time and that I may contact Hilltop Medical Clinic at any time at the address above and obtain a current copy of the Notice of Privacy Practices. In addition, Hilltop Medical Clinic will post a copy of any revised Notice of Privacy Practices in its lobby for my review.

I understand:

● I may request in writing that Hilltop Medical Clinics restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that Hilltop Medical Clinic is not required to agree to my requested restrictions, but if Hilltop Medical Clinic does agree it is bound to abide by such restrictions.

● I have the right to review the notice prior to signing this Acknowledgement, and also the right to revoke this Acknowledgement in writing except to the extent that Hilltop Medical Clinics have already taken action in reliance thereon.

● I personally must sign a medical records release authorization before my specific health information will be released to anyone by Hilltop Medical Clinic.

● I may refuse to sign this consent Form. However, if I do so, Hilltop Medical Clinic is NOT required to see and/or treat me as a patient.

If you request restrictions on the use or disclosure of your health information, you must verbally notify the receptionist to make the appropriate documentation.

I attempted to obtain the patient’s signature in acknowledgment of receipt of the Notice of Privacy Practices, but was unable to do so as documented below:

Date:_____________ Initials:_______Reason:____________________________________

Effective Date:1/1/2016

Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

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Reason for refusal.

Medicare Billing Policy

Medicare Billing Policy

EFFECTIVE 4/1/2020 ~ DUE TO COVID, WE ARE “ACCEPTING ASSIGNMENT” ON MEDICARE UNTIL FUTURE NOTICE.

Hilltop Medical Clinics are NON-Participating Provider for Medicare.

Medicare patients are required to pay for their medical care at the time of service. We do not Accept Assignment on Medicare claims. We have a provider number with Medicare for them to process the claim and pay directly to you.

We are payment at the time of service. Hilltop Medical Clinic is required by law to submit your claims to Medicare and/or their TPA, and they will respond directly to you. Please do not submit your own claims to Medicare. Allow 30-45 days before following up with Medicare on an unpaid claim.

Medicare forwards your claims to your supplemental insurance company if you have that insurance on file with Medicare. Hilltop Medical Clinic does not receive an EOMB Explanation of Medicare Benefits from Medicare to do your 2ndary billing. Please contact Medicare with your supplemental insurance information if you have not done so.

I understand that Hilltop Medical Clinicdoes not accept MEDICARE with MEDI-CAL (aka Medi-Medi) patients. You confirm that you do not have MEDI-CAL as a primary OR a supplemental to Medicare.

Medicare will consider reimbursement on the Physician, X-ray and some injection charges. We are notifying you that Medicare will NOT reimburse you for the following services (nor will Hilltop Medical Clinic) and by signing this you understand you will owe for the following services:

Laboratory text performed in our office that get applied toward your deductible.
Handling charges on laboratory test sent to an outside lab.
Various allergy or hormone injections or immunizations (i.e.tetanus). This excludes Flu & Covid Vaccines.
General Physical exams and the corresponding test, including TB tines or PPD tests.
All medical supplies (i.e. Orthopedic, suture tray, dressing, etc.).
Oral prescription drugs purchased from our clinic.

At this time, we are unaware of any other services we provide which are determined by Medicare to be not covered because they are not reasonable and necessary for treatment of illness or injury.

My signature below authorizes Hilltop Medical Clinic to release medical information about me to the HHS for Medicare & Medicaid Services and its agents to determine these benefits payable to related services. I understand my signature requests that payment be made to HMC or me and authorizes release of medical information necessary to process this claim.

I have been informed of Hilltop Medical Clinic’s policy in regards to me, the Medicare patient. The entire bill will be strictly my responsibility to pay today. HOWEVER, EFFECTIVE 4/1/2020 ~ DUE TO COVID, WE ARE “ACCEPTING ASSIGNMENT” ON MEDICARE UNTIL FUTURE NOTICE.

Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

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Effective 4/1/22 we are no longer a participating provider for Cigna and United Healthcare.
I acknowledge Medicare Billing policiesNot Signed

Medicare Signature on File

Medicare Signature on File

EFFECTIVE 4/1/2020 ~ DUE TO COVID, WE ARE “ACCEPTING ASSIGNMENT” ON MEDICARE UNTIL FUTURE NOTICE.

Dear Medicare patients – we are required to now use this updated format for our “signature on file” requirement..

I request the payment of authorized Medicare benefits be made either to me or on my behalf to R.P.C.M.G., Inc. dba Hilltop Medical Clinic, for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to CMS Centers for Medicare & Medicaid Services, any information needed to determine these benefits payable to related services.

Please be advised that you may be treated by one of our Mid-Level Practitioners (N.P or P.A.) at Hilltop Medical Clinic. It is a requirement of Medicare that if you are seen by one of these Medical Providers as a patient with no M.D. or D.O. “on site” we bill your services accepting assignment for that particular office visit. In this situation, we would bill Medicare and not require payment at the end of your visit, any payments made would be sent to Hilltop Medical Clinic by Medicare.

You may receive a statement for any balance unpaid by Medicare, such as copay or deductible amounts. Our usual office policy of Non-Assignment and Payment in full would be followed if you are seen by our M.D., D.O. or Mid-Level practitioner when a physician is “on-site”.

I understand my signature requests that payment be made and authorize release of medical information necessary to pay claim. If other health insurance coverage is indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. Per billing law requirements, my claim will be submitted by this office to Medicare for processing. I understand this office is primarily on a non-assignment basis with Medicare. Therefore, Medicare will respond directly to me. HOWEVER, EFFECTIVE 4/1/2020 ~ DUE TO COVID, WE ARE “ACCEPTING ASSIGNMENT” ON MEDICARE UNTIL FUTURE NOTICE.
Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

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I acknowledge receipt of HIPAA policiesNot Signed

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Check here if you accept these terms. If you requested our special Telemed service, the doctor will call you ASAP.

If you answered no to the infectious illness questions, please arrive at the clinic before 4pm to be seen today.

If you answered YES to infectious illness, please WAIT AT HOME for a call from our office to make an assessment.

I understand a Tele-Medicine visit is charged the same amount as an in-person doctor visit. I am responsible for any copay/deductible based on my insurance coverage, and if I have no coverage, the cash price.

Telemedicine virtual doctor visits require video chat in addition to audio.

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Infectious Illness Screen (Thank you for being forthcoming)

Reason for your visit (required)

Please Use Legal Name

Consent for Treatment

Consent for Treatment

Scope of Treatment

Billing Policy

Billing Policy

HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Medicare Billing Policy

Medicare Signature on File

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