Section 5A: OFFICE INSURANCE POLICES
* - Required Fields
While we do not participate with insurance carriers, we will do our best to facilitate the processing of your claims.
Please enter your Primary Insurance below.
Please enter your Secondary Insurance below.
While we do not accept insurance, this information will help us to facilitate the processing of your claims.
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- FINANCIAL RESPONISIBILITY POLICY -
Dr. Friedman's office has advised me that they DO NOT participate with my insurance.
My decision to have care acknowledges this fact.
I understand that his office will do their best to facilitate the processing of my claim, but that I am responsible for all professional services at the time of service.
By signing my intials below, I hereby acknowledge that I have read and understood the above policy.
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE POLICY -
Release of Information
This is necessary to allow our office to release information to Medicare regarding your care.
Please review and sign the acknowledgement. Thank you.
I certify that the information given to by me in applying for payment under Title XVIII of the Social Security Act is correct. (This indicates that the information I have submitted is accurate.)
I authorize any holder of medical or other information about me to release to the Social Security Administrative and Health Care Financing Administrations or its intermediaries or carrier, or to the billing agent of this physician or supplier which is Robert Friedman, M.D., any information needed for this or a related Medicare claim. (This permits our office to release information to Medicare.)
I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment. (This allows this form to be used as a proxy for your permission.)
Medicare Part B Confirmation
This is to confirm that you have government-issued Medicare (Medicare Part B).
We do not participate in any other form of Medicare (Medicare Advantage). If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees. (This indicates that you have government-issued Medicare Part B and not Medicare Advantage.)
Supplmental Policy
I do have a supplemental (secondary) insurance plan that is intended to pay any copayment remaining after Medicare processes the charges for my visit.
Should the insurer not cover these charges, I will be personally responsible to pay the copayment for any services rendered after Medicare preocess their payment.
By signing my initials below, I herby acknowledge that I have read and understood the above policies.
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE POLICY -
Release of Information
This is necessary to allow our office to release information to Medicare regarding your care.
Please review and sign the acknowledgement. Thank you.
I certify that the information given to by me in applying for payment under Title XVIII of the Social Security Act is correct. (This indicates that the information I have submitted is accurate.)
I authorize any holder of medical or other information about me to release to the Social Security Administrative and Health Care Financing Administrations or its intermediaries or carrier, or to the billing agent of this physician or supplier which is Robert Friedman, M.D., any information needed for this or a related Medicare claim. (This permits our office to release information to Medicare.)
I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment. (This allows this form to be used as a proxy for your permission.)
Medicare Part B Confirmation
This is to confirm that you have government-issued Medicare (Medicare Part B).
We do not participate in any other form of Medicare (Medicare Advantage). If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees. (This indicates that you have government-issued Medicare Part B and not Medicare Advantage.)
Supplmental Policy
I will personally be responsible to pay the copayment for any services rendered after Medicare processes their payment.
By signing my initials below, I herby acknowledge that I have read and understood the above policies.
- REFRACTION POLICY -
Medicare do NOT cover refracrion, i.e., the prescribing of spectacles.
The physician is expected to charge the patient directly for these services. The fee for this service is $80.00 per encounter.
By signing my initials below, I hereby acknowledge that I have read and understood the above policy.
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE ADVANTAGE POLICY -
Robert Friedman, MD, PC participates only with government-issued Medicare (Medicare Part B).
We do not participate in any other form of Medicare (Medicare Advantage).
If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees.
By signing my initials below, I acknowledge that I have read and understood the above policy.
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
MEDICAID POLICY
THIS OFFICE DOES NOT ACCEPT MEDICAID.
If you have Medicaid, either as primary or secondar insurance, you will be personally financially responsible for any fee for services. The form below indicates your acknowledgement of this responsibility.
I acknowledge that I am fully aware of my rights and privileges as a Medicaid enrollee, and that I do understant that I can receive the medical service that I am commissioning from Robert Friedman, M.D. for free or reduces costs by seeking attendance from a participating provider.
I request that Dr. Robert Friedman provide me with medical services at the costs stated by his office and recognize that I will personally responsible for these expenses at the time of services. These charged will NOT be submitted to Medicaid or any authorized agency and are not eligible for reimbursement by any agency.
I authorize Dr. Friedman's office to collect the above stated fees by all coventional methods.
By signing my intials below, I confirm that my insurance is Medicaid. I acknowledge that you do not accept my Medicaid plan and that I will be responsible for the full fee. I here by acknowledge that I have read and understood the above policy.
- HIPPA FORM -
This is a link to the Government HIPPA Policy. Please click on it to review the policy if you wish.
LINK TO HIPPA
I reviewed the HIPPA Notices of Privacy Practices that is displayed and operative in the office of Robert Friedman, MD, PC.
By signing my initials below, I hereby acknowledge that I have ready and understood the above policy.