New Patient Registration Form

INSURANCE INFORMATION

SECONDARY INSURANCE COMPANY

Thank you for choosing Ghosn Family Medicine. We realize that you have a choice in medical providers and are pleased that you have chosen to seek care with us. The staff at Ghosn Family Medicine strives to exceed expectations in care and service to make your experience with us as comfortable and stress-free as possible. Our goal is to provide quality medical care in a timely manner. In order to do so, we have listed our office policies. These policies enable us to better utilize time for our patients. Please feel free to contact our office if you have any questions regarding our policies.

OFFICE HOURS
Our office is available Monday-Friday 8:00-5:00 Saturday 8:00-12:00 and may be reached at 706-265-8002. Please listen to the recording to ensure you choose the correct line to serve your needs. The phones are forwarded after hours for emergency needs only. If you need a prescription refill or test results, please call during regular business hours.

APPOINTMENTS
Ghosn Family Medicine is committed to providing quality care to our patients. To ensure timely continued care, we encourage patients to schedule appointments in advance for follow-up due dates. Same-day appointments are reserved for sick visits only and will not be utilized for medicine refills or checkups.

CANCELLATION OF AN APPOINTMENT
We realize things do come up, and schedules change. If you are unable to attend an appointment, please be courteous and call Ghosn Family Medicine as soon as possible.

If it is necessary to cancel your scheduled appointment, we require that you call (1) one business day in advance. Appointments are in high demand, and your early cancellation will give another person the ability to have access to timely medical care.

NO SHOW POLICY
A failure to present at the time of a scheduled appointment will be recorded in your medical chart as a "no-show." An administrative fee of $25.00 will be billed to your account. You will be sent a letter alerting you to the fact that you failed to show up for a scheduled appointment and did not cancel within one (1) business day of the appointment, along with the bill for the administrative fee. A copy of the letter will be placed in your medical records.

Three (3) “no-shows" within one (1) calendar year will result in a temporary suspension of services. In order to reinstate services, you will be required to meet with your Primary Physician within 30 days of the third no show letter to evaluate your situation. In the event you do not respond and/or schedule an appointment within the 30 days, we will consider your patient status as terminated.

**Please note that “no-show” charges are patient responsibility and will not be billed to your insurance company.

INSURANCE
Ghosn Family Medicine accepts most insurance plans. If you have any questions, please call our billing department at 706-429-1298. It is the patient's responsibility to inform our office of any changes in insurance coverage. Failure to do so could cause delay or denial of insurance payment. Patients are responsible for co-pays at the time of service. If applicable, our billing department will bill you for services not covered by your insurance (as stated in your insurance contract).

PAYMENTS
Ghosn Family Medicine accepts cash, Mastercard, Discover, Visa, and American Express. It is the policy of our practice to make all reasonable attempts to collect outstanding balances should they accrue.

FORMS/LETTERS
We understand that, at times, various forms or letters may be required to assist you with your healthcare needs. The staff at Ghosn Family Medicine will be happy to complete forms and write medical letters as necessary upon your request. However, because this can be time-consuming, an appointment may be necessary. Please allow 7-10 days to complete the requested forms/letters.

MEDICAL RECORDS
Per HIPAA guidelines, copies of medical records must be requested in writing. To ensure your privacy, a form for the release of medical information must be completed before receipt of these materials. All patients can request a copy of their medical records once, free of charge. Additional copies may be requested at a·cost of $0.75 per page. The law allows Medical Offices 30 days to complete requests for records. However, our medical records department makes every effort to respond to these requests promptly.

PRESCRIPTION REFILLS & PHARMACY INFORMATION
Please inform Ghosn Family Medicine which pharmacy to use and update us if this should change. Please allow one to two business days for refill requests. We encourage our patients to review their medications prior to their office appointments and request refills at that time if needed.

Please note that we do not fill controlled (including narcotic) medications or order antibiotics over the phone or by electronic request. These requests require an appointment.

OFFICE BEHAVIOR
Our office staff work very hard to provide each patient with kind and caring treatment. Therefore, disrespectful and aggresive behavior towards the staff of Ghosn Family Medicine will not be tolerated and is grounds for discharge.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION

INTRODUCTION
Ramzi Ghosn, M.D. is required by law to maintain the privacy of "protected health information." Protected health information includes any identifiable information that we obtain from you or others that relates to your physical or mental health, the healthcare you received, or payment for your healthcare.

As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to privacy-protected health information. This notice also discusses the uses and disclosures we will make of your protected health information. We must comply with the provisions of this notice, although we reserve the right to change the terms of this notice from time to time to make the revised notice effective for all protected health information we maintain.

PERMITTED USES AND DISCLOSURES
We can use or disclose your protected information for the purposes of treatment, payment and healthcare operations. For each category, we will explain what we mean and give some examples. However, not every use or disclosure will be listed.

Treatment means the provision, coordination, or management of your healthcare, including consultations between healthcare providers regarding your care and referrals for healthcare from one healthcare provider to another. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Therefore, the doctor may review your medical records to assess whether you have potentially complicating conditions like diabetes.

Payment means activities we undertake to obtain reimbursement for the healthcare provided to you, including determinations of eligibility and coverage and utilization review activities. For example, prior to providing health care services, we may need to provide your health plan information about your medical condition to determine whether the proposed course of treatment will be covered. When we subsequently bill your health plan for services rendered to you, we can provide them with the information regarding your care if necessary to obtain payment.

Healthcare operations means the support functions of our practice related to treatment and payments, such as quality assurance activities, case management, receiving and responding to patient complaints, physical reviews, compliance programs, audits, business planning, development management and administrative activities. For example, we may use your medical information to evaluate the performance of our staff when caring for you. We may also combine medical information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. In addition, we may remove information that identifies you from your health information so that others can use this de-identification information to study healthcare delivery without learning who you are.

This information may include, but is not limited to, treatment related to psychiatric or psychological, drug and/or alcohol, or Acquired Immune Deficiency Syndrome/HIV.

I understand that this information is to be disclosed for the following purpose and that purpose only:

Continuity of care

I understand that this consent is subject to revocation by me at any time, and unless an earlier date is specified, the consent will automatically expire 12 months after the date below. I also understand that this information may be bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records. Redisclosure of this information to any other party other than the one listed is prohibited without any additional written consent on my part.