(870) 236-6930

for an appointment

Clinic Forms

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

MEDICAL RELEASE FORM

PATIENT INFORMATION

PRIVACY PRACTICES

PRIVACY POLICY AGREEMENT

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Fonticiella Medical Clinic

4000 Linwood Drive Ste G

Paragould, AR 72450

Phone (870) 236-6930

Fax (870) 239-8065

info@fonticiellamedicalclinic.com

 

Clinic Hours

Monday 8:00 am - 5:00 pm

Tuesday 8:00 am - 5:00 pm

Wednesday 8:00 am - 5:00 pm

Thursday 8:00 am - 5:00 pm

Friday  8:00 am - 5:00 pm

Saturday Closed

Sunday Closed

Insurance/Billing Information:

We will submit primary and one supplemental insurance claim for you subject to your having given us current insurance information prior to services being provided. This will be filed at no charge to you.

 

Copayments/deductibles/Due balances:

These must be paid at the time of service and we expect timely payment of any balance or non-covered services. Approximately 45 days after we submit your claim to your insurance company any unpaid charges will appear in the “patient’s responsibility” space on your statement and payment must be received before the next billing date. The financial responsibility for service provided to you remains yours.

 

Insurance ID:

You are required to present your current insurance card prior to each visit. If the insurance information is inaccurate the balance is the patient’s responsibility.

 

Appointments:

Office visits are by appointment only to help us keep your waiting time to a minimum. It is our goal to follow our time schedule as closely as possible. However, if an emergency arises that would cause a delay, we

will attempt to keep you informed of your doctor’s schedule. If you need to cancel an appointment, please call as soon as possible, preferably at least 24 hours. That way your time can be given to another patient. There is a no show fee for missed appointments; a phone call can prevent this.