Notice to MAHV Patients and Visitors
Cancellation /Reschedule and No Show Policy
This policy has been established to help us serve you better.
We understand situations arise in which you must cancel your appointment. It is therefore requested if you must cancel or reschedule your appointment, you provide more than 24 hours notice. This will enable another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations/reschedules made less than 24 hours notice, we are unable to offer that appointment to other patients. Please be advised that excessive cancellations/reschedules even if they fall within the policy guidelines may result in your discharge from care. Office appointments which are cancelled/rescheduled with less than 24 hour’s notification will be subject to an initial $25 cancellation fee and a subsequent fee of $50.00 for each cancellation in less than 24 hours thereafter. Please note fees may differ for initial appointments for specialists that arc cancelled, rescheduled or no showed for.
Patients who do not show up for their appointment without a call to cancel the office appointment will be considered as a NO SHOW. Patients who No Show two (2) or more times in a twelve (12) month period, may be dismissed from the practice thus being denied any future appointments. Additionally, patients will be subject to an initial fee of $25.00 for a No Show appointment, and a 50.00 fee for each subsequent No Show visit.
The cancellation/reschedule and no show fees are the sole responsibility of the patient and must he paid in full before the patient’s next appointment.
We understand special unavoidable circumstances may cause you to cancel/reschedule within 24 hours. Fees in this instance may be waived. but only with approval by administration. MAHV believes a good physician/patient relationship is based upon understanding and communication. If you have questions about our cancellation/reschedule and no show fees, please call our office at (845) 338-7140 to speak with one our Patient Service Representatives.
PATIENT FINANCIAL RESPONSIBILITY FORM
Thank you for choosing Medical Associates of the Hudson Valley for your healthcare needs. We are honored by your choice and are committed to providing high quality, patient focused medical care. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities
– The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for their treatment and care.
– We are pleased to assist you by billing to your insurance company. However, the patient is required to provide us with the most correct and updated information about their insurance and will be responsible for any charges incurred if the information provided is not correct or updated.
– Patients are responsible for the payment of co-pays, co-insurance. deductibles. and all other procedures or treatment not covered by their insurance plan Procedures may include (but are not limited to):
— Dexa scans (Bone Density).
— Infusion Therapy
– Payment is due in full at the time of service. We accept cash, check. and most major credit cards at our office.
– Patients may incur and are responsible for the payment of additional charges These charges may include (but are not limited to):
— Copays/Coinsurance/Deductibles resulting from additional services performed during preventative visits.
— $50 Charge for returned checks
— $50 Charge for cancellations. reschedules and no shows within less than 24 hours.
— $0.75 Charge per page for the copying and distribution of patient medical records.
By my signature below, I hereby authorize Medical Associates of the Hudson Valley to release medical and other information acquired in the course of my examination and/or treatment (with the exceptions stipulated below) to the necessary insurance companies. third party payers. and/or other physicians or healthcare entities required to participate in my care
By my signature below, I authorize Medical Associates of the Hudson Valley personnel to communication by mail, answering machine message. and/or email according to the information I have provided in my patient registration information.
_ I consent to all of the above.
_ Waiver of Patient Authorizations
I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and to submit claims to insurance at my discretion
This agreement is between PATIENT NAME and Medical Associates of the Hudson Valley (MAHV).
1. By signing this contract for narcotic administration, I indicate that I understand the discussion about the use of narcotic medications, including side effects and I agree to start this treatment under the terms set by MAHV.
2. I have had a chance to ask questions regarding the use of narcotic medications and other alternative medications as well.
3. I understand that it is against state law to conceal my medication history from any medical provider. I agree to reveal my medications to any medical provider treating me and I agree to inform the office of any medications prescribed by any other providers.
4. My provider may discuss my care and medications with providers I have been referred to and other appropriate individuals.
5. I will comply with all aspects of the treatment plan, including but not limited to, physical therapy, behavioral management, and self-help programs.
6. I understand that the benefit of the narcotic medications will be evaluated periodically using the following criteria of pain relief, increase in general functions, increase in exercise, completion of rehabilitation program, return to work, maintenance of job, etc.
7. I will be honest about my drug and alcohol history including any past or current use.
8. I certify or agree to the following:
a) I am not currently abusing illicit or prescription drugs.
b) I have never been involved in the sale, illegal possession, diversion or transport of controlled substance (narcotics, sleeping pills, nerve pills, or pain killers).
c) I am not pregnant and that I will use appropriate contraception during my course of treatment.
d) Sharing my narcotics is strictly prohibited. Any sharing will result in immediate cancellation of my prescription refills.
9. I agree to give a minimum of 24 hour notice for prescription renewals.
10. Prescriptions will be dated and picked up for the date they are due. If the medication is due on a weekend, the prescription can be picked up on that Friday. The prescription will be dated for the renewal date.
11. No other person will pick up prescriptions besides myself unless other arrangements were made with my physician.
12. I will not modify my dosages or dosing frequency without authorization from my provider.
13. Changes of dosages or frequency of administration will be made only during face to face medical appointments. These changes cannot be made by telephone, fax or any other ways of communication.
14. I agree my medications may be decreased or stopped at any time or for any reason by my provider.
15. Renewals are contingent upon keeping your scheduled appointments. I will be seen by my provider at least every three months unless other arrangements were made between my provider and myself.
16. I understand that my medications will not be replaced under any circumstances including lost, stolen or damaged medications.
17. I agree to allow MAHV to perform urine and blood tests to make sure I am taking my medications correctly and to check for the use of other substances which may interact with prescribed medications.
18. I understand that narcotic medications may become addictive.
19. If I violate these conditions, my provider may not refill my medications and/or may require that I obtain help regarding my use of these medications.
20. If I am non-compliant or uncooperative with the Physicians or office staff, it may result in my dismissal from the practice with a 30 day notice.
I fully understand the explanations regarding the benefits and the risks of this method of treatment. I agree to the use of narcotic medication in treatment of my pain problem. This contract has been fully explained to me, I have read it or have had it read to me, and I understand it. I have had the opportunity to ask questions and have received acceptable answers. I agree to the terms of this contract.
SURPRISE BILL DISCLOSURE
Medical Associates of the Hudson Valley participates with many health insurance companies and you can find a list of those plans on the home page of our website at www.mahv.net. Since not all health plans have a network and may not contract with providers, your health plan may not be listed. Please feel free to call our office at 845-338-7140 if you have questions about participation or what your out of pocket cost for treatment received will be if we don’t participate with your current plan.
_ I understand my physician is in network with my insurance company.
_ I understand my physician is out of network with my insurance company which will result in a higher out of pocket expense and I agree to pay those amounts.
It is also important to know that our physicians may refer you to other facilities that may not participate with your insurance. You should check prior to scheduling an appointment to determine if your insurance is accepted and to inquire about their out of network rates for non-covered services.
Following is a list of facilities that we currently utilize for outside services along with their contact information:
PO Box 2240, Burlington, NC 27216-2240
3 Giralda Farms, Madison, NJ 07940
481 Edward H. Ross Dr, Elmwood Park, NJ 07407
45 Pine Grove Ave, Kingston, NY 12401
150 Sawkill Rd, Kingston, NY 12401
1 Columbia St, Poughkeepsie, NY 12601
14 Raymond Ave, Poughkeepsie, NY 12603
The Wound Healing Center
396 Broadway, Kingston, NY 12401
Health Alliance (Kingston & Benedictine)
741 Grant Ave, Lake Katrine, NY 12449
Northern Dutchess Hospital (Healthquest)
6511 Spring Brook Ave, Rhinebeck, NY 12572
Vassar Brothers Medical Center
45 Reade PI, Poughkeepsie, NY 12601
MidHudson Regional Hospital
241 North Rd, Poughkeepsie, NY 12601
Ellenville Regional Hospital
10 Healthy Way, Ellenville, NY 12428
I have read and understand the above.
MAHV prohibits bringing a pet (a domestic animal kept for pleasure or companionship) into MAHV-controlled buildings and premises, with the exception of service animals for a person with disabilities.
According to the Americans with Disabilities Act (ADA), a service animal is defined as “any animal individually trained to work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding individuals with impaired vision, alerting individuals to an impending seizure or protecting individuals during one, and alerting individuals who are hearing impaired to intruders, or pulling a wheelchair and fetching dropped items.”
A person with a disability uses a service animal as an auxiliary aid. In compliance with the ADA, service animals are welcome in all buildings on company property and may attend any class, meeting or other event. There may be an exception to certain areas.
Requirements of service animals and their owners include:
- All animals need to be immunized against rabies and other diseases common to that type of animal. All vaccinations must be current.
- Animals must wear a rabies vaccination tag.
- All dogs must be licensed per state law.
- Service animals must wear an owner identification tag (which includes the name and phone number of the owner) at all times.
- Animals must be in good health.
- Animals must be on a leash, harness or other type of restraint at all times, unless the owner/partner is unable to retain an animal on leash due to a disability.
- The owner must be in full control of the animal at all times. The care and supervision of the animal is solely the responsibility of the owner/partner.
Reasonable behavior is expected from service animals while on company property. The owners of disruptive and aggressive service animals may be asked to remove them from MAHV facilities. If the improper behavior happens repeatedly, the owner may be told not to bring the service animal into any facility until the owner takes significant steps to mitigate the behavior.
Cleanliness of the service animal is mandatory. Consideration of others must be taken into account when providing maintenance and hygiene of service animals. The owner/partner is expected to clean and dispose of all animal waste.