To avoid delays when you arrive, please complete …

1 Welcome to Flagler Family medicine , PA. We respect your time and would like to make your visit as efficient as possible. Arrive 15 minutes before your scheduled appointment time To avoid delays when you arrive, please complete the enclosed forms in advance then mail, fax 904-808-4608 or return them to our office 2-3 days prior to your scheduled appointment. please note: We will reschedule your appointment if the paperwork is not provided in advance or incomplete. Thank you, Flagler Family medicine Management Welcome to your Patient Centered Medical Home Thank you for choosing us to be part of your healthcare team. We look forward to working with you to make sure you receive the care you need and keep you healthy and happy. Our practice provides personalized primary care, preventive and health maintenance care and access to various specialty services. We also fully coordinate care for our patients with disabilities, chronic illness and other complex medical conditions.

2 We hope that the information provided on this guide will answer many of the questions you may have about our practice. contact us after-hours care Office hours: This office is open Monday-Thursday If you would like to speak to a clinician to help you 7-6:30, Friday 7-4, Saturday 9-1 decide how to treat an illness after hours or to help you decide whether to go to the emergency room, Main phone number: (904) 826-3469 call (904) 826-3469. This is a special after-hours Use this number to schedule appointments, answer service we offer and they will have access to your your general questions, and connect you with team records and your team as needed. members. If you receive care at an emergency room or urgent Web address: care center, please let us know by calling (904) 826- You can also contact us by secure messaging via 3469 within 48 hours so we can assist with follow - your dedicated patient portal through this website.

3 Up care as needed. Our locations Palm Coast special accommodations 28 Old Kings Rd N, Ste A, Palm Coast FL 32137. PH: 386-225-4670 The Practice is accessible by wheelchair. FX: 904-808-4608 People with limited sight should bring a companion St. Augustine/Flagler Hospital Campus to ensure clear communication. People with limited 130 Health Park Blvd, St. Augustine FL 32086. hearing can request deaf interpreter services free of PH: 904-826-3469. FX: 904-808-4608 charge. St Augustine/Shoppes of Murabella 52 Tuscan Way, Suite 205, St. Augustine FL 32092 please let us know if you prefer to receive your care in PH: 904-826-3469 Spanish. FX: 904-808-4608. East Palatka 199 Hwy 17 South, Suite 101, East Palatka FL 32131. PH: 386-325-5232. FX: 904-808-4608. All Physicians at Flagler Family medicine are Board Certified in Family Practice. Todd Batenhorst, MD Linda Clonch, MD Frederick Dolgin, MD Andrew Gunn, MD Michael Look, DO.

4 Carlos Sanchez, MD Erin Scales, MD Warren Whitlock, MD Christopher Zub, DO Jerry Weed, DPM. Joann Fritsch, ARNP Melissa Senior, ARNP Cathy Youngstrom, PA Suzanne Weed, ARNP Sarah Swiatowicz, PA. we are your family physician appointments payment options If you would like to speak to a nurse about your We participate in most insurance plans, including symptoms, follow the phone menu options to speak Medicare. Be sure to check with us to confirm with your physician's nurse. that we accept your insurance before making an appointment. If you have an emergency illness or symptom that requires immediate, urgent attention, call 911. If you please be prepared to pay your co-pay and/or need an appointment for illness or a symptom, call patient balance at the time of service. We accept (904) 826-3469 and press option #2. checks, Visa, MasterCard, Discover, American Express, and cash. If you need a check-up, follow-up visit, or annual visit please call the main number (904) 826-3469 We are happy to answer questions, discuss and press option #2.

5 Payments or your bill anytime by calling (904) 826- 3469 and press option #5 for the billing department. Patients who are more than 15 minutes late may be required to reschedule their appointments. You may pay your bill online at appointment checklist Your insurance card. prescriptions A list of current prescription and non-prescription For refills of prescriptions please contact your medications, vitamins and supplements. pharmacy. A good description of the problem, how long you If you need a written prescription, leave a voice have had it and how it affects you. message on our prescription line. A list of questions you would like to discuss with your provider. please allow 48 hours for us to refill your prescriptions. We will contact you only if there A list of other health care providers you have visited. is a problem or we have a question about your prescription refill request. Laboratory & Diagnostic Tests please remember that refills can only be given to patients who have been seen within the past year.

6 If your provider orders laboratory and/or diagnostic If you have not been seen for more than a year, you tests you will be referred to the facility preferred by will need to schedule an appointment. your medical insurance plan. If you have questions about a new prescription or A member of your team will call you to discuss the about discontinuing medication(s), please call your results of testing and needed follow up. provider's nurse. All laboratory and diagnostic results will be available After hours, urgent refills will be handled by the on your patient portal after the physician reviews doctor on call. the results. If you have not received your results within four weeks, please call our office. ~Patient Information~. Last Name: _____First Name: : _____. Street Address: _____Apt #_____. City: _____State: _____Zip Code: _____. Home Phone: _____Cell:_____. Work Phone: _____EXT:_____ Email Address:_____. Birth Date: _____Social Security #:_____.

7 Gender: Male Female Transgender Marital Status: Married Single Divorced Widowed Student ? : Not a student Full-time student Part-Time Student Employer Name: _____. Employer Address: _____. ~Emergency Contact~. Name: _____Relation:_____. Home Phone: _____Cell:_____Work:_____. **If the person resides with you please give us a second contact person**. 2nd Name: _____Relation:_____. Home Phone: _____Cell: _____Work:_____. ~Insurance~. Guarantor: Last Name: _____First Name _____MI:_____. Date of Birth: _____Social Security: _____. Telephone: _____. Primary Insurance Name: _____. Address: _____. Effective Date: _____Subscriber Number: _____. Group Number: _____. Secondary Insurance Name: _____. Address: _____. Effective Date: _____Subscriber Number: _____. Group Number: _____. ~Preferred Pharmacy~. Name: _____Address:_____. FINANCIAL POLICY. Thank you for choosing us as your health care provider. We are committed to your treatment.

8 please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment: 1. All patients must complete our information and insurance form before seeing the doctor. 2. For your convenience we accept cash, check, Visa, MasterCard, American Express and Discover. We have contracts with most commonly used insurance companies. please check to see if we accept your insurance. If we do not accept your insurance policy, as a courtesy, we will bill your company. Your insurance policy is a contract between you and your insurance company. We are not a party of that contract. If we bill your insurance company and they have not paid your account in full within 45 days, the balance may be automatically transferred to your credit card or billed directly to you. Any subsequent visits must be paid in full at the time the services are rendered.

9 please be aware that some insurance companies, including Medicare, may determine treatment to be non-covered or find it not to be reasonable or necessary. If such a determination is made, you will be responsible for such services. Such services will be billed and payment is due upon receipt of bill. Regarding insurance plans where we are a participating provider: All co-pays and deductibles are due at the time of treatment. If there are any additional procedures performed, they may be subject to an additional Co-Payment, Deductible or Co-Insurance. please refer to your HealthCare Plan for additional information. In the event that your insurance coverage changes to a plan where we are not a participating provider, refer to the above paragraph. Usual and customary rates: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of what constitutes a usual and customary rate.

10 Minor patients: The adults accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa, MasterCard, Discover or payment by cash or check at the time of service has been verified. Missed appointment: Unless canceled at least 24 hours in advance, you may be subject to $ no- show fee at the physician's discretion. please help us serve you by keeping scheduled appointments. Co-pays and Balances: Co-pays are due at the time of service. If we need to bill you for the co-pay, there will be an additional $ processing fee. You will also be asked to pay any outstanding patient balance. Insufficient Fund Fee: Checks that are returned will be charged a $ insufficient funds fee. Collection Fee: Unpaid balances may be turned over to an outside collection agency.