New Patient Form

We would like to thank you for choosing Health & Wellness Center as your medical provider. We have written this policy to keep you informed of our current office policies.

OFFICE HOURS: Our Lake Forest office is open: 949-770-7301

Monday-Friday 8:00-5:00pm

Our San Clemente office is open: 949-493-9344

Monday-Thursday 9:00am-5:00pm Closed Fridays

APPOINTMENTS: We see patients by appointment only. Same day appointments are usually available for urgent or sudden illnesses.

AFTER-HOURS AND EMERGENCIES: For a serious emergency call 911 right away. If you are not sure and you call our office, please be sure to tell the person who answers the phone it is an emergency. After hours you will reach our voice mail which will instruct you on how to contact one of our providers.

URGENT NEED OR SUDDEN ILLNESS: We will refer you to urgent care. It is your responsibility to make sure it is covered by the insurance.

CANCELATIONS: Please call within 24 hours if you are unable to keep your scheduled appointments. This allows us to provide that time slot to another patient. There is a $50 fee for missed appointments.

TREATMENT OF MINORS: Patients under the age of 18 must be accompanied by a parent or guardian, or have written permission for treatment, from a parent or guardian.

LABWORK: If lab work is ordered, you will be referred to a lab based on your insurance, however, it is the patient responsibility to make sure lab and tests are covered by insurance. For cash patient’s it is your responsibility to look for a low-cost laboratory. If unable to find a low-cost lab we will refer you to Pacific Medical Lab.
COMPLETE PHYSICAL EXAMS: We believe that routine, annual complete physical exams with screening labs tests are very important to the maintenance of good health. However, insurance benefits vary. Some policies cover “wellness” and others cover visits when you have a complaint. Please verify your insurance benefits prior to your appointment to determine what is covered by the insurance plan.

TEST RESULTS: If you have diagnostic testing i.e. lab, x-ray, echo, ultrasound, sleep study, please schedule a follow-up appointment, within 7-10days, to go over the results with your physician. There will be a copy/ coinsurance. Results will not be given over the phone.

PRESCRIPTION AND REFILLS: The best time to get a prescription refill is at your appointment. If you need to call for a refill, don’t wait until you have run out. Most refills require the doctor’s approval. Contact your pharmacy and have them fax us a “refill request”. We ask that you give us 5 working days for the prescription to be called in. Call them first to see if it is ready. Some medications have potential side effects that must be mentioned. We require check-ups every 1 or 4 months depending on medications. Be sure to keep those follow-up appointments. Some prescriptions cannot be called in. The prescription must be printed.

NO INSURANCE:  Payment will be due at the time of services. The initial consultation will cost $150.00 and each follow up appointment will be $125.00

INSURANCE:  Although we are contracted with most insurances, it is the patient’s responsibility to make sure that our physician is in their plan. It is also the patient responsibility to know their insurance benefits. We will need all your demographic and insurance information prior to your appointment. We will also request an update on this information approximately every six months. We ask that at the time of your visit you bring your insurance card and photo id as well as any other forms that will assist in making sure that your claim is filed correctly. At the time of service, you will be responsible for all fees that are not covered by your insurance, including copays, co-insurance, deductibles, and non-covered services or items received. The co-pay cannot be waived by our practice as it is a requirement placed on you by your insurance carrier.

REFERRALS:  Sometimes this can be done the day of your appointment, sometimes it may take several days, depending on your insurance and or the urgency of the situation. Someone will contact you as soon as referral authorization is obtained. It is your responsibility to ensure your specialist receives your test results. Please understand that it can take a few weeks to get an appointment with your specialist. This is not something we have control over.
DISABILITY, INSURANCE FORMS, ATTENDING PHYSICIAN STATEMENTS: There will be a charge of $25.00-$50.00 for the completion of medical forms and you may be required to schedule an appointment. Payment is due before filling out these forms. Please allow 7-10 days for the completion of these forms. FMLA forms require that you come in for an appointment.
MEDICAL RECORDS:  We will provide you with a copy of your medical records upon request and for a fee. You will need to sign release consent prior to having them copied. Please allow up to 30 days for this request to be processed.
BILLING: If you receive a bill from us, and have any questions, please call our billing department immediately. If you cannot pay your entire balance, please call to make payment arrangements.

COLLECTIONS: Accounts that are not paid within 30 days will begin our in-house collection process. If your balance becomes 65 days old, your doctor will be notified and you pay be subject to dismissal from the practice.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT: HIPAA requires that entities take the appropriate standards to protect the privacy of patient information. HIPAA’s Privacy Rule provides that all information that can be used to identify a patient is “Protected Health Information”. Furthermore, all PHI must only be used and transmitted to service the patient’s physical or mental health, provide health care to the individual, and submit and process the payment of the individual’s healthcare services.
ACKNOWLEDGEMENT: I acknowledge that I have received and read a copy of the Health and Wellness Center and Financial Policies.