Jane O. Barnwell, M.D. Physical Medicine and Rehabilitation 3100 N West St Ste 200B • Flagstaff Arizona 86004 Phone: 928-714-7090 • Fax: 928-220-8879
Patient Profile
Last name
First name
Mid. Initial
Address
If work related, date of injury:
City
State
Zip
Phone
Home
preferred
Work
Cell
Email
Password for secure email
Female
Male
single partnered divorced
married widowed
Date of birth
Social security number
Your occupation:
Spouse’s/partner’s name:
Should we share your medical information and records with your spouse/partner? yes no
Referring doctor:
Problem(s) you are seeing Dr for:
Preferred pharmacy name:
City:
Location (if more than one in city):
Other doctors - attorneys to send records to (name & address):
Emergency contact name:
Relationship
Phone #
Nearest relative not living with you - name:
Employer’s name
Phone number
Person responsible for bill (not your insurance company) Self
Primary insurance company name
Customer service phone #
Policy holder name
Policy holder date of birth
Policy holder Soc Sec #
Specialist Copay
ID number
Group name & number
Member number
Secondary insurance company name
General Policies
We specialize in occupational injuries and the management of pain and chronic fatigue. To handle other medical problems you may have, you should have a primary care physician. We are not available after hours or on weekends. If you have an emergency after hours, you will need to contact your primary care physician, an extended hours clinic or the hospital emergency room.
Payment Policies
1. If you have an insurance we are contracted with, you will be expected to pay at the time of service the copay, deductible or percentage as contracted with your insurance company.
2. When you pay the total bill at the time of service we will give you a 25% discount for medical care. Any payments from your insurance company to us will be immediately reimbursed to you.
3. You may set up a payment plan with us of the higher of $50.00 or 10% of your bill each month debited directly from your account. To initiate this payment plan, request a debit authorization form from our office.
4. If you have not made other prior payment arrangements with our office, we will send you statements monthly. The total amount is due 10 days after we send the statement to you.
Please understand that whether you have insurance or not and whether we participate in your insurance program or not, you are responsible for payment of the fees for medical services provided. Checks or debits returned unpaid will be charged $25.00. Overdue accounts will be charged 2% for each month (24% APR) they are overdue. Amounts three months overdue will be filed with the appropriate court at which time the court filing and notification fees will be added to your bill. Each time that we need to go to court to collect moneys owed us, we will add $50.00 to your bill to cover the internal office collection costs. You are also responsible for other costs to us in collecting the fees you owe our office including but not limited to reasonable attorney and billing service fees and court costs.
When you make an appointment with our office, we reserve that time for you. We require 24 hours notice or by noon Friday for Monday appointments if you have to cancel or reschedule. If you do not give us timely notice, you will be charged $150.00 for the initial visit, $50.00 for the follow up appointments. If you have an emergency and need to cancel with less than the required notice, call us as soon as you can to cancel and we may be able to waive or reduce the charge. We usually give you a reminder call the day before your appointment. Sometimes emergency, staffing or other issues prevent us this courtesy. The responsibility to remember your appointments ultimately rests with you.
We keep records of the health care services we provide you. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your records, obtain a copy of them or get more information about them by contacting our Office Manager or General Manager. You may also add your own statement(s) into your records if you feel something is incorrect. We keep your medical information strictly confidential; however for your convenience and medical care, we have general policies to share your medical information with the following people: We will share your medical information with your spouse or partner, the doctors, attorneys and insurance companies listed on the front of this profile, your pharmacy and with other health care providers currently providing you care. We will leave messages for you to call our office that prescriptions have been sent to your pharmacy or the date and time of your appointment on your home answering machine, with anyone that answers your home phone or to your personal email address. We will leave messages for you to call our office with anyone that answers your work phone. All other communications to anyone else of your medical information will require your direct approval. This is a short summary of our privacy policies. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. The Notice of Privacy Practices is posted in the reception area at our office and on our website at www.barnwellmd.com/privacy. You may also call our office to have us send you a copy. I acknowledge receipt and have read and understand the Notice of Health Information Practices regarding my provider's participation in the statewide Health Information Exchange (HIE), or I previously received this information and decline another copy. We will attempt to contact you twice to give you non critical infomation. You agree to these policies unless you direct us otherwise in writing.
From time to time, we need to share portions of your records with third party payers to receive payment for your medical services. We also need to share portions of your records with services we contract with and agencies to help us with our billing. You authorize us to release your personal and medical information necessary to process payment of your bill.
If we refer you to another doctor or order tests and x-rays or you choose to see another doctor, the other office will need to see your medical records. We also need to request medical records from other offices. You authorize release of your medical information as necessary for continuation of your medical care.
We use facsimile or mail to transmit patient records. We are extremely careful to ensure that the facsimile or mail goes to the right person and we only send facsimile of patient records to offices that are used to handling confidential patient records. However, it is possible that a mistake can be made. You agree to hold us harmless if such a mistake is made.
I understand and agree to the policies above.
Signature: Date:
Electronic signature in conformance with the Electronic Signatures in Global and National Commerce Act for any signature on this website. You may receive a paper copy of this document and cancel this signature by contacting the office of Jane Barnwell, MD.