Bella Vista Internal Medicine Jigna Patel, MD PLLC Gilbert .

Bella Vista Internal MedicineJigna Patel, MD PLLC2680 S Val Vista Dr, Ste 131 Bldg 6Gilbert, AZ 85296PATIENT ENROLLMENT INFORMATIONNAME (Last, First, Middle Initial)BIRTHDATESS #ADDRESSCITY, STATE, ZIPPRIMARY PHONE - May we leave a detailedALTERNATE PHONEPRIMARY LANGUAGEENGLISHEMPLOYERWORK PHONEEMAIL ADDRESSmessage at this phone?YesNoMay we contact you at work?YesNoGENDERMALEFEMALESPANISHOTHERGUARANTOR INFORMATION (person who is financially responsible for patient amount due)NAME (Last, First, Middle Initial)BIRTHDATEADDRESS (if different from patient)CITY, STATE, ZIPPRIMARY PHONEALTERNATE PHONEEMPLOYERSS#GENDERMALEFEMALEEMAIL ADDRESSWORK PHONE NUMBERRELATIONSHIP TO PATIENTSPOUSEPRIMARY INSURANCENAME OF INSURANCE COMPANYPOLICY NUMBERNAME OF OWNER OF POLICYRELATIONSHIP OF OWNER OF POLICY TO PATIENTOWNER OF POLICY DATE OF BIRTHCOPAY AMOUNTGENDERMALEFEMALEDEDUCTIBLE AMOUNTGROUP NUMBEROWNER OF POLICY EMPLOYERSECONDARY INSURANCENAME OF INSURANCE COMPANYPOLICY NUMBERNAME OF OWNER OF POLICYRELATIONSHIP OF OWNER OF POLICY TO PATIENTOWNER OF POLICY DATE OF BIRTHCOPAY AMOUNTGENDERMALEFEMALEDEDUCTIBLE AMOUNTGROUP NUMBEROWNER OF POLICY EMPLOYER

Bella Vista Internal MedicineAUTHORIZED INDIVIDUALS TO WHOM MEDICAL INFORMATION MAY BE RELEASED TO:NAME (Last, First, Middle Initial)RELATIONSHIPDate of BirthPRIMARY PHONENAME (Last, First, Middle Initial)RELATIONSHIPDate of BirthPRIMARY PHONENAME (Last, First, Middle Initial)RELATIONSHIPDate of BirthPRIMARY PHONENAME (Last, First, Middle Initial)RELATIONSHIPDate of BirthPRIMARY PHONENAME (Last, First, Middle Initial)RELATIONSHIPDate of BirthPRIMARY PHONEPHARMACY INFORMATIONNAME OF PHARMACYADDRESSOTHER INFORMATIONHOW WERE YOU REFERRED TO BELLA VISTA INTERNAL MEDICINE (JIGNA PATEL, MD)FriendPhysician, NameYellow PagesNewspaper, NameOtherI hereby agree that this information is correct and I understand that I must provide in writing any changesto the above information. I hereby understand that if I provide incorrect insurance information that I willbe financially responsible for the balance due for each date of service:Patient Name (Please print)Signature of Patient and/or Legal GuardianDatePage 2 of 2

Bella Vista Internal MedicineJigna Patel, MD PLLC2680 S Val Vista Dr, Ste 131 Bldg 6Gilbert, AZ 85296AUTHORIZATION TO RELEASE MEDICAL RECORDSI herby authorize the release of photocopies of my medical records in the possession andcontrol of the below named individual/facility, employees and/ or agents for the purposehereof. Medical records shall include all confidential HIV related information (A.R.S. Section35-6511); communicable disease related information (A.R.S. Section 36-651); confidentialalcohol and drug abuse related information (42CRF Section 2.1 et al); and confidentialmental health diagnosis-treatment information unless otherwise directed by me. Descriptionof information to be released (i.e. date of service, test results, immunization records, etc).whose date of birth isName of PatientBirth DateFROM:Bella Vista Internal MedicineJigna Patel, MD PLLC2680 S Val Vista DR, STE 131 Bldg 6Gilbert, AZ 85296Phone: (480)899-0311 / Fax: (480)814-1462TO:Please transfer and/or disclose ALL the following information:ooAll medical records, files, charts, reports and other associated health information.The following specific Protected Health Information (PHI) (Check ALL that apply)o Medical Records & Chartso Immunization Recordso X-Rays or Diagnostic Results/Lab Resultso Other (Please Specify)TO BE RELEASED FOR:Printed Patient NameDate of BirthPrinted Name of Person Completing FormRelationship to PatientSignature of Person Completing FormToday’s Date

Bella Vista Internal MedicineJigna Patel, MD PLLC2680 S Val Vista Dr, Ste 131 Bldg 6Gilbert, AZ 85296OFFICE AND FINANCIAL POLICYThank you for choosing Bella Vista Internal Medicine (Jigna Patel, MD PLLC) foryour health care. We are committed to providing quality medical care for you. Inorder to reduce potential misunderstandings, our office has adopted the followingOffice and Financial Policy. We require that you read it and agree to abide by it priorbeginning treatment.InsuranceYour insurance policy is a contract between you and your insurance plan. We cannotefficiently bill your insurance company unless you provide us with current and validinsurance information. We will file claims to those plans with which we have acontractual agreement. As a courtesy, we will file claims to those plans with whichwe do not have a contractual agreement as unassigned and the insurance companywill send the payment directly to you, therefore full payment is expected at the timeof service.All health plans are not the same and they do not always cover the same services orfacilities. In the event that your health plan determines that a service is “notcovered” you will be responsible for the entire charge. This office is not responsiblefor disputing decisions made by your insurance carrier regarding coverage. Paymentfor services rendered is due by the 1st day of the month after the charge has printedon your statement.We expect you to familiarize yourself with the benefits and limitations of yourinsurance policy including, but not limited to: deductible and co-payment amount aswell as approved labs, radiology facilities, and hospitals contracted with your plan. Itis your responsibility to notify our office when either your insurance plan or benefitschange. Any cost incurred by this office because of incorrect information youprovided to us will be passed on to you.If you have insurance coverage with a plan with which Bella Vista InternalMedicine (Jigna Patel, MD PLLC) does not participate charges for your care andtreatment are due at the time of service, unless prior financial arrangements havebeen set up by our Office Manager.No InsuranceIf you have no insurance coverage Bella Vista Internal Medicine (Jigna Patel, MDP L L C ) has implemented a Self Pay Fee Schedule for those services that are‘Medically Necessary’.Deductibles/Copays/PaymentsOur insurance contracts require us to collect deductible amounts and copays at thetime of service. These amounts will be collected prior to service being rendered. Foryour convenience we accept VISA and MasterCard in addition to personnel checksand cash. If your check is returned to us for insufficient funds, we will assess aBVIM Fin Policy V02.docPage 1 of 2

Bella Vista Internal MedicineJigna Patel, MD PLLC2680 S Val Vista Dr, Ste 131 Bldg 6Gilbert, AZ 85296service charge equal to the bank fees assessed to Bella Vista Internal Medicine(Jigna Patel, MD PLLC).AppointmentsOur goal is to provide the best possible care and physician availability to each of ourpatients. Our policy is to request you to call and cancel appointments 24 hours priorto scheduled appointment. Please call us, as early as possible, when you know youwill need to reschedule and/or cancel an appointment.InformationI hereby agree that the enrollment information is correct and I also agree that anychanges to the enrollment information will be communicated to Bella Vista InternalMedicine (Jigna Patel, MD PLLC) as required to fulfill the medical and financialobligation for services rendered. I hereby understand that if I provide incorrectinsurance information that I will be financially responsible for the balance due foreach date of service.Narcotic PolicyNarcotic medications are difficult to regulate and can be addictive. The providers ofBella Vista Internal Medicine (Jigna Patel, MD PLLC) will avoid their use wheneverpossible. Patients who require narcotics will be required to sign a ‘Narcotic Contract’and each case will be reviewed individually and referred to a Pain Management Clinicfor continued pain management as deemed medically necessary per individual.AuthorizationI hereby request and consent that my medical records and non written records besent to my referring physicians, those physicians or ancillary facilities that I amreferred to by the Bella Vista Internal Medicine (Jigna Patel, MD PLLC) and to myinsurance company or its agents that may be authorizing treatment. I furtherunderstand that my medical records may contain sensitive information and herebyauthorize the release of all confidential HIV related information, communicablediseases related information, drug and alcohol abuse/treatment information andmental health diagnosis/treatment information to the above.I hereby authorize payment directly to the attending physician for medical and/orsurgical benefits, if any from the insurance carrier to Bella Vista Internal Medicine(Jigna Patel, MD PLLC) if paying cash; I am responsible to pay at the time of service.Patient Name (Please print)Signature of Patient and/or Legal GuardianDateBVIM Fin Policy V02.docPage 2 of 2

Bella Vista Internal Medicine Jigna Patel, MD PLLC 2680 S Val Vista Dr, Ste 131 Bldg 6 Gilbert, AZ 85296 BVIM Fin Policy V02.doc Page 2 of 2 service charge equal to the bank fees assessed to Bella Vista Internal Medicine (Jigna Patel, MD PLLC).Appointments