Healthcare That Focuses on Your Wellness
Payment Policies
You are financially responsible for anything insurance does not cover. All copays are due and payable at each visit. The amount your insurance will allow and pay for and your financial responsibility is determined by your insurance company and the policy you have chosen. Your claim will be processed according to the benefits of your insurance plan. The deductible, co-insurance and co-pay are your financial responsibility. It is your responsibility to understand your insurance plan. $35 No Show Fee for any Missed Appointment that was not cancelled or rescheduled 24 hours prior to the appointment. Please be considerate and call at least 24 hours before your appointment if you cannot come in.
Please do not wait until your last pill to call for a refill. There is a 72 hour turn around for prescription refills. If you have not seen the physician in six months, the prescription will be denied.
Yes, I agree with the below Privacy Practices
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By Consenting/signing this form, I understand that:
Yes, I agree with the below Medical Services Agreement
Medical Consent: I consent to any treatments or procedures which may be performed on an outpatient basis (including emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the physicians, staff, or other health care providers of Onyx Medical assisting my care.
Financial Agreement: I understand that all charges are due at the time of service. I agree to pay Onyx Medical for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals. Acceptable forms of payment include Cash, Visa, MasterCard, Discover, and American Express. If I am a non-insured patient, I agree to pay for my visit in full at the time of service. If Onyx Medical is a participating provider with my insurance company, I understand that my co-pay, coinsurance, deductible, and/or any outstanding balances are due at the time of service. I understand that my insurance policy is a contract between myself and my insurance company, Onyx Medical is not involved. In order for Onyx Medical to file claims and accept payments from my insurance carrier, I understand that I must present current insurance information at each visit and that Onyx Medical will need to verify my health insurance coverage. In the event that Onyx Medical is not able to verify my insurance eligibility and benefits before my visit, I agree to pay for my visit in full at the time of service. A refund will be issued if my insurance pays for the visit. I also understand that I am financially responsible for any services not covered by my insurance company. When my spouse or a financial guarantor signs this agreement, the spouse or the financial guarantor shall be jointly and individually liable with me. Should my account(s) be referred to an attorney or a collection agency for the collection, the undersigned shall pay the actual attorney’s fees (including costs) and collections expenses incurred in addition to other amounts due. Unpaid accounts referred to outside agencies for collection shall bear interest at the current rate per year from the date of referral.
Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health plans to be made to Onyx Medical for any services furnished to that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize Onyx Medical to disclose portions of or all of my records, including my medical records by any person or corporation which is or may be liable for all or any portion of Onyx Medical charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker’s compensation carriers. I authorize Onyx Medical to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Onyx Medical any information required to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Release of Medical Information: I hereby authorize Onyx Medical to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care.
Notice of Privacy Practices: By signing this form, you acknowledge receipt of the “Notice Of Privacy Practices” of Onyx Medical. Our “Notice of Privacy Practices” provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our “Notice of Privacy Practices” is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting Onyx Medical 407-214-3051.
In House Pharmacy: I understand that, for my convenience, Onyx Medical can dispense some prescription medications necessary to treat my medical condition(s). I understand that my insurance will not be billed for medications dispensed and that my pharmacy benefits DO NOT apply to this service. Any medication(s) dispensed in the office are my responsibility and are an additional charge to my office visit charge. I also understand that if I prefer to use an outside pharmacy, a prescription can be provided to me at no additional charge.
Personal Valuables: Onyx Medical shall not be liable for the loss of or damage to any money, documents, jewelry, glasses, dentures, furs, or other articles of unusual value and shall not be liable for loss or damage to any personal property. Onyx Medical, A medical corporation and the patient or the patient’s representative, hereby enters into this agreement. The undersigned certifies that he/she has read and agree to the foregoing, and is the patient, the patient’s representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.
