Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

First Name:

Last Name:

Email Address:

Mobile phone number:

Date of Birth:

1. Insurance - We participate with most major insurances. For a complete list, please refer to the signage posted at check-in. Knowing your insurance benefits is your responsibility. All patients must complete our patient information packet prior to receiving treatment. We must obtain a copy of your driver's license or valid id and current insurance card to provide medical services. If you are unable to provide us with a current copy of your insurance card, payment for services is expected at time of service. If your insurance coverage changes, please notify us before the next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance could be billed to you. It is the patient's responsibility to provide us with the most current insurance information and bring their card to each visit.

2. Claims Submission - We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance; we are not a part of that contract. We will collect credit card information to be kept on file and will run that card for an amount of no greater than $50.00 for any balance not covered by your insurance company.

3. Referrals- It is the patient's responsibility to ensure any required referrals for treatments are provided to the practice before the visit, visits may be rescheduled, or the patient may be responsible due to lack of the referral.

4. Self-Pay(Payment- Patients that do not have insurance are expected to pay for medical services at the time services are rendered. If the visit exceeds a balance of $300 after payment for the office visit, we will retain a copy of your credit card information on file and run the balance in 30 days from dates of service.

5. Forms- If you have disability, FMLA papers ect, we will be more than happy to assist you in filling them out. Our facility charges a $ 15 form fee that must be paid prior to form completion. Medical record fees are set at $10 up to 20 pages, thereafter .50 per page is charged.

6. Collections- Once your account goes beyond 90 days, it is subject to collection action. If your account is turned over to collections you will not be able to receive medical care including prescription refills until balance in full has been paid. Payment arrangements cannot be made once the account has been turned over. Patients who are having financial difficulties should contact our billing department at 336-286- 5505 to work out a satisfactory payment plan.

7. Return Check- A fee of $30 will be assessed on any return checks .

Check for your acknowledgement
Please sign in the space provided below acknowledging you have rend and understand the Financial Policy. Again thank you for choosing Traid Primary Care. We look forward to servicing your healthcare need todays and in the future.

Date:

Patient/ Guardian Signature:

Please review to ensure the details are correct before completion.