Thank you for choosing Lake Forest Internal Medicine (LFIM). We are committed to providing high quality medical care. Your clear understanding of all our policies is important to our professional relationship. Our policies are as follows:
Insurance: We participate in many insurance plans. If you are not insured by a plan that we do business with, payment in full is required at each visit. If you are insured by a participating plan, but you do not have an up-to-date insurance card, payment in full may be required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions regarding your coverage, including wellness care.
By signing this form, you authorize LFIM to release the necessary information in order to submit and process your insurance claims, and assign benefits directly to LFIM. All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Our staff will verify billing information at each and every visit. Current information is essential to obtain timely payment from your insurance company.
I understand that some, and perhaps all, of the services I receive may not be covered by my insurance or not considered “reasonable or necessary” by Medicare or other insurers. I agree to pay for any services which have been determined by my insurance plan to be “non-covered. Payment in full for these services is due at each visit.
I understand that if I am not insured, or am self-pay at the time of service, then payment in full is due at the time of service .
LFIM will submit your claims and help to get them paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply in a timely manner with your insurance company’s request. Please be aware that the balance of your claim is your responsibility, whether or not your insurance company pays your claim. If your insurance company does not pay your claim in 90 days, the balance may be billed to you.
If your insurance changes, please notify LFIM as soon as possible, so we can make the appropriate changes to help you receive your maximum benefits. Please note that most insurance companies have time-sensitive filing constraints, and if LFIM does not receive your insurance information in a timely manner, you will be responsible for the payment in full.
-Non-Payment: If a balance remains unpaid after 60 days, your account may be placed with our outside recovery service, you may be responsible for a reinstatement fee along with payment in full of past due amounts prior to seeing your provider, or you may be discharged from the practice. If this occurs, you will be notified by mail that you have 30 days to find a new medical provider. During that 30 day period, our physicians will treat you on an emergency basis only. Call our billing department with questions at 847-816-3084.
-There will be a yearly charge for completion of forms not completed at the time of your appointment.
-Missed Appointments: You may be charged for a missed appointment if you do not notify LFIM at least 24 hours prior to your scheduled appointment time.
-Returned Checks-NSF: You will be charged for any returned personal check.
-Prescription Policies: We refill prescriptions during office hours only. Please call your pharmacy and ask them to fax us your refill request(s) so that we may confirm the correct medication/dosage and pharmacy location. We fill refill requests within 48 hours. Patients may also request prescription refills through the patient portal. Please plan ahead so you do not run out of medication.
-Patients under the age of 18 are legally entitled to confidentiality with regard to what is discussed during office visits. They are encouraged by our providers to discuss sensitive issues with close family members, but the providers need only disclose information if the patient is at risk for endangering him/herself.
-Medical Records: 72 hours is required for all copies of medical records. There will be a fee for those copies.
-Routine/Preventative Care: Routine healthcare and wellness visits (yearly physicals/wellness exams) are extremely important. Most insurance plans will not cover both a well visit and a “sick” visit or a “follow-up” on the same day. If there are multiple issues to be discussed at your physical, you may be asked to schedule another visit. Please note that not all insurance plans cover preventative care (wellness). Check with your insurance company for wellness benefits. Wellness visits must be coded as such, and altering coding in an attempt to obtain coverage is considered insurance fraud. Please do not ask our office to do this.
-Medicare: We accept Medicare assignment. As a Medicare patient, you are responsible for the difference between the approved charge and the amount Medicare pays, as well as any deductible amount. If you have supplemental insurance and provide the necessary information, we will be happy to submit the claim for you.
-Workman’s Compensation: We do not accept Workman’s Compensation coverage. You must pay at time of service.
-Accident Claim: If you are here as a result of an accident, and you do not want us to file your health insurance claim, you must pay at time of service. We will provide a copy of your bill, which you may submit to your insurance carrier.
I acknowledge that this practice is using an Electronic Health Record information system (the EHR system) in coordination with Northwestern Memorial Health Care, which is the parent organization for Northwestern Memorial Hospital (NMH), and Northwestern Lake Forest Hospital (NLFH). The collection and use of all information through the EHR system is primarily for the purpose of treatment of patients by this medical practice, NMH, NLFH, and other medical practices of physicians on staff at either hospital who have a treatment relationship with the patient and provide services in a clinically integrated care setting. All information collected through the EHR system may also be shared with, and used by NMH, NLFH, and certain other hospitals, academic institutions, and healthcare providers that perform medical or research activities in conjunction with NHM and NLFH (including, but not limited to Northwestern University, the Feinberg School of Medicine, Children’s Memorial Hospital, and the Rehabilitation Institute of Chicago) for the following health-related activities, including without limitation: a) conducting peer review, b) promoting quality assurance, c) mortality and morbidity analysis, d) conducting utilization review, e) evaluating and improving the quality of care, f) promoting and maintaining professional standards, g) examining costs and maintaining cost control, h) conducting medical audits, i) assisting the medical staff membership and credentialing process, j) performing data quality management, k) improving the efficiency and effectiveness of healthcare, l) conducting research in a manner that complies with applicable law, m) copying data from the EHR system and any related database and incorporating it into a data warehouse maintained by Northwestern University which may be accessed for any of the activities described above or in the Privacy Practice Notice. The EHR system is not equipped to segregate such data as mental health, HIV, drug and alcohol abuse, and genetic testing information, and such data will be included in the information used and disclosed as described above. The patient further acknowledges that the information in the EHR system will contain information regarding treatment for mental health and developmental disabilities, HIV, AIDS, substance abuse, and genetic testing, and counseling, and consents to the use and disclosure of such information for treatment, payment purposes, and those activities described above and in the Practice Policy Notice as such consent may be required by state law.
I understand that I may opt out of the option of sharing my health record information.
I have read and understand all policies and agree to abide by their guidelines.
I understand that by signing this agreement, I authorized the provision of clinical services.
*SIGNATURE REQUIRED ELECTRONICALLY AT FRONT DESK AT TIME OF SERVICE. DO NOT SIGN THIS FORM.