Professional Documents
Culture Documents
WELCOME PATIENT
We have news to share. Our name is changing to The Center for Cancer Care. We have partnered with Gwinnett Medical Center to improve and develop a comprehensive and innovative cancer center for our community and patients. There are a few changes in the check-in and billing process, but ultimately the quality care you receive from our physicians and staff youre familiar with remains the same. This is a quick reference to help explain the partnership as well as some answers to questions you may be having. Any other questions can be answered by our associates. Presenting Consents/Forms Some of our forms have changed and now reflect Gwinnett Medical Centers agreements/consents. These consent forms will only have to be signed once a year. Here is a list of the forms well go over. Admission/Registration Agreement This is a consent that allows us to treat you. Please read and then sign and date. Guarantee of Payment Please read and sign. By doing so, you are guaranteeing payment for treatment and services. You are authorizing us to submit a claim with your insurance carrier. Notice of Privacy Practices Acknowledgment Please read and sign the bottom of the form indicating that we have offered you our notice of privacy practices, also known as HIPPA. (Mark through the Designation of personal representative) Email Consent Form This is a consent form that allows us to discuss how we will contact you. Patient History Form This form will give us a detailed history of your medical background. Notice of Privacy Practices (take home) This form is for you to keep. Notice of Patient Rights (take home) This form gives you a list of your rights as a patient. Indigent Care Trust Fund (take home) Now, being part of the hospital if you become unable to pay your bill with us you may be eligible for the financial assistance program. Please see one of our benefits counselors if you think you may be eligible. Medicare Co-insurance (Snellville) (Take home) CMS requires us to notify you that our office is now considered part of an outpatient hospital-based facility. This may change the co-insurance amount you may owe. By signing this document, you acknowledge your visits with us will be submitted to Medicare as an outpatient hospital-based facility and that your co-insurance amount may increase. Center for Cancer Care FAQ Handout (Take home) Every insurance plan has different policy provisions. We will work with your company to discover the individual benefits your specific plan has to offer. Well share with you those details once weve contacted them. Your co-pay or co-insurance may differ from the past since you are now being seen in an outpatient hospital-based facility.
Please supply the following information. This document will be part of the medical record.
FULL NAME:
(FIRST) (MIDDLE) (LAST) (AGE)
MARITAL STATUS:
(CITY) (STATE) (ZIP)
HOME PHONE: EMPLOYER: EMAIL: SPOUSES NAME: SPOUSES DOB: EMPLOYER: EMERGENCY CONTACT (NOT LIVING WITH YOU): ADDRESS:
(NO. & NAME OF STREET)
(CITY)
(STATE)
(ZIP)
TEL #: NAME OF INSURANCE COMPANY: POLICY HOLDER: POLICY #: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: PATIENTS SIGNATURE:
MOBILE #:
GROUP #:
*1-32763*
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(1) Needle Sticks, such as shots, injections, intravenous lines, or intravenous injections (IVs). The material risks
associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be less effective) or refusal of treatment. Physical tests, assessments and treatments such as vital signs, internal body examinations, wound cleansing, wound dressing, rang of motion checks, and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscularskeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures and/or refusal of treatment, no practical alternatives exist. Administration of Medications whether orally, rectally, topically or through the eye, ear or nose. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration and/or refusal of treatment, no practical alternatives exist. Drawing Blood, Bodily Fluids or Tissue Samples such as those done for laboratory testing and analysis. The material risks associated with this type of Procedure include, but are not limited to, paralysis or partial paralysis, nerve damage, infection, bleeding and loss of limb function. Apart from long-term observation and/or refusal of treatment, no practical alternatives exist. Insertion of Internal Tube such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and/or difficulty urinating after catheter removal. Apart from external collection devices or refusal of treatment, no practical alternatives exist.
FORM 2-32643 INITIATED 08/2012 Page 1 of 2
(2)
(3)
(4)
(5)
*2-32643*
____________________ Date
For Gwinnett Hospital Use Only: INTERPRETIVE SERVICE USED ON THIS ENCOUNTER Interpreter used - Name or Number____________________________________________________ Date/Time_____________________________ Language __________________________________
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GUARANTEE OF PAYMENT/ ASSIGNMENT OF BENEFITS/ AUTHORIZATION TO PROCESS CLAIMS Center For Cancer Care
GUARANTEE OF PAYMENT/ASSIGNMENT OF BENEFITS: In consideration of the Hospital's advancing credit to me for my hospital care and services, I hereby irrevocably assign and transfer to Gwinnett Hospital System and treating Physicians all benefits and payments now due and payable or to become due and payable to me under any insurance policy or policies, under any replacement policies thereof, under any self-insurance program, under any third-party actions against any other person or entity, or under any other benefit plan or program (hereafter referred to as Benefits) for this or any other period of hospitalization and related outpatient care. I understand and acknowledge that this assignment does not relieve me of my financial responsibility for all hospital charges and treating Physician charges incurred by me or anyone on my behalf, and I hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Hospital and treating Physicians by any Benefit plan or program. Furthermore, I agree to pay all costs of collection, reasonable attorneys fees and court costs incurred in enforcing this payment obligation. AUTHORIZATION TO PROCESS CLAIMS & RELEASE OF INFORMATION: I authorize Gwinnett Hospital System and the independent contractor physicians and/or professional corporations that render services to me to process claims for payment by my insurance carrier on my behalf for covered services provided to me at Gwinnett Hospital System. I authorize the release of necessary information, including medical information, regarding medical services rendered during this admission or any related services or claim, to my insurance carrier(s), including any managed care plan or other payor, past and/or present employer(s), Medicare, CHAMPUS/TRICARE, authorized private review entities and/or utilization review entities acting on behalf of such insurance carrier(s), payers, managed care plans and/or employer(s), the billing agents and collection agents or attorneys of Gwinnett Hospital System and/or the independent contractor physicians and/or professional corporations, my employer's Worker's Compensation carrier, and, as applicable, the Social Security Administration, the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government, and/or any other federal or state agency for the purposes(s) of satisfying charges billed and/or facilitating utilization review and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted to release health record data and/or copies to my attending and/or admitting healthcare professional and/or any consulting healthcare professional and/or any healthcare professional I may be referred to for follow-up care. I further authorize Gwinnett Hospital System and any other healthcare provider or professional rendering services to me to obtain from any source medical history, examinations, diagnoses, treatments and other health or insurance authorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providing medical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of state or federal law. A photocopy of this Authorization may be honored. MEDICARE PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a RELATED Medicare claim. I request that payment of authorized benefits be made on my behalf. I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form.
SIGNED: WITNESS:
*1-32651*
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compliance, provided that such entity has, or has had in the past, a relationship with the patient who is the subject of the information. Sharing of PHI Among the Hospital and the Medical Staff. As an organized health care arrangement, the Hospital and the members of the Medical Staff will share with each other PHI that they collect from you as necessary to carry out their treatment, payment and health care operations relating to the provision of care to patients by GHS. Other Uses and Disclosures For Which Authorization is Not Required. In addition to using or disclosing PHI for treatment, payment and health care operations, GHS may use and disclose PHI without your written authorization under the following circumstances: As Required by Law and Law Enforcement. GHS may use or disclose PHI when required to do so by applicable law. GHS also may disclose PHI when ordered to do so in a judicial or administrative proceeding, to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, the location of the crime or victims, or the identity, description, or location of a person who committed a crime, to report a death or injury resulting from a boating accident, or for other law enforcement purposes. For Public Health Activities and Public Health Risks. GHS may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence, reactions to medications or product defects or problems, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition. For Health Oversight Activities. GHS may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws. Coroners, Medical Examiners, and Funeral Directors. GHS may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law. Organ, Eye, and Tissue Donation. GHS may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation. Research. Under certain circumstances, GHS may use and disclose PHI for medical research purposes. To Avoid a Serious Threat to Health or Safety. GHS may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public. Specialized Government Functions. GHS may use and disclose PHI of military personnel and veterans under certain circumstances. GHS may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations. Workers Compensation. GHS may disclose PHI to comply with workers compensation or other similar laws. These programs provide benefits for work-related injuries or illnesses.
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Fundraising Activities. Your PHI may be used to contact you in an effort to raise money for the Hospital. Your PHI may be disclosed to a foundation related to the Hospital. Such disclosure would be limited to contact information, such as your name, address and phone number and the dates you required treatment or services at the Hospital. The money raised in connection with these activities would be used to expand and support the Hospitals provision of health care and related services to the community. If you do not want to be contacted as part of these fundraising activities, please notify the Gwinnett Hospital System Foundation in writing. Appointment Reminders; Health-related Benefits and Services; Marketing. GHS may use and disclose your PHI to contact you and remind you of an appointment at GHS, or to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs. GHS may use and disclose your PHI to encourage you to purchase or use a product or service through a face-to-face communication or by giving you a promotional gift of nominal value. Disclosures to You or for HIPAA Compliance Investigations. GHS may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. GHS must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the Secretary) when requested by the Secretary in order to investigate GHS compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Uses and Disclosures To Which You Have an Opportunity to Object. You will have the opportunity to object to these categories of uses and disclosures of PHI that GHS may make: Patient Directories. Unless you object, GHS may use some of your PHI to maintain a directory of individuals in its facility. This information may include your name, your location in the facility, your general condition (e.g. fair, stable, etc.), and your religious affiliation, and the information may be disclosed to members of the clergy. Except for your religious affiliation, the information may be disclosed to other persons who ask for you by name. Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, GHS may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. GHS may also notify those people about your location or condition. Other Uses and Disclosures of PHI For Which Authorization is Required. Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations you have the right to revoke in writing. Regulatory Requirements. GHS is required by law to maintain the privacy of your PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to abide by the terms described in this Notice. GHS reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all of the PHI it maintains. Before GHS makes an important change to its privacy policies, it will promptly revise this Notice and post a new Notice in all patient entry locations. You have the following rights regarding your PHI: You may request that GHS restrict the use and disclosure of your PHI. GHS is not required to agree to any restrictions you request, but if GHS does so it will be bound by the restrictions to which it agrees except in emergency situations. Effective February 17, 2010, GHS is required by the Health Information Technology for Economic and Clinical Health Act (the HITECH Act) to honor an individuals request to restrict disclosures of PHI to health plans for
FORM 4-18967 REV. 07/2010
payment or health care operations purposes if the PHI pertains solely to items and services paid for by the individual in full. You have the right to request that communications of PHI to you from GHS be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be made in writing and sent to the Privacy Officer. GHS will accommodate your reasonable requests without requiring you to provide a reason for your request. Generally, you have the right to inspect and copy your PHI that GHS maintains, provided that you make your request in writing to the Hospitals Department of Health Information Management. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), GHS will inform you of the extent to which your request has or has not been granted. In some cases, GHS may provide you a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you request paper copies of your PHI or agree to a summary of your PHI, GHS may impose a reasonable fee to cover copying, postage, and related costs. To the extent capable, GHS will comply with your request for a copy of your PHI in an electronic format. If GHS denies access to your PHI, it will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If GHS does not maintain the PHI you request, if it knows where that PHI is located it will tell you how to redirect your request. If you believe that your PHI maintained by GHS contains an error or needs to be updated, you have the right to request that GHS correct or supplement your PHI. Your request must be made in writing to the Hospitals Department of Health Information Management, and it must explain why you are requesting an amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), GHS will inform you of the extent to which your request has or has not been granted. GHS generally can deny your request if your request relates to PHI: (i) not created by GHS; (ii) that is not part of the records GHS maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, GHS will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and GHSs denial attached; and (iii) complain about the denial. You generally have the right to request and receive a list of the disclosures of your PHI that GHS has made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). The list will not include disclosure for which you have provided a written authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for the Hospitals patient directory or to persons involved in your health care; (iv) for national security or intelligence purposes; or (v) to correctional institutions or law enforcement officials. You should submit any such request to the Hospitals Department of Health Information Management, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), GHS will respond to you regarding the status of your request. GHS will provide the list to you at no charge, but if you make more than one request in a year you may be charged a fee for each additional request. You have the right to receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically. You can receive a copy of this Notice at our Web site, http://www.gwinnetthealth.org. To obtain a paper copy of this Notice, please contact the GHS Privacy Officer. You may complain to GHS if you believe your privacy rights with respect to your PHI have been violated by contacting a Hospital Patient Representative or the GHS Privacy Officer and submitting a written complaint. GHS will in no manner penalize you or retaliate against you for filing a complaint regarding GHS privacy practices. You also have
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the right to file a complaint with the Secretary of the Department of Health and Human Services. If you have any questions about this Notice, please contact the GHS Privacy Officer by mail at 1000 Medical Center Boulevard, Lawrenceville, Georgia 30046, by telephone at (678) 312-3900 or by email at ghsprivacyofficer@gwinnettmedicalcenter.org. If you have any questions about your medical records, please contact the Medical Records Department by mail at 1000 Medical Center Boulevard, attn Medical Records, Lawrenceville, GA 30046, or by telephone at (678)-312-4490. Effective Date: April 14, 2003.
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*1-32766*
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Highest Grade Completed: _________________ Religion: _______________________________ Alcohol use: ____________________________ Heart attack Other heart disease Lung disease High blood pressure Stroke Seizures Arthritis Head injury Cancer Phlebitis Asthma High cholesterol
LIST ALL MEDICATIONS Drug Dose Frequency 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________ 4. __________________________________________________________________________________ 5. __________________________________________________________________________________ LIST ALL PROCEDURES Procedure Date Hospital 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________ 4. __________________________________________________________________________________ 5. __________________________________________________________________________________ ALLERGIES NONE DYE LATEX
DRUG: Please List Drug and Reaction: Other: Please List with Reaction: FAMILY HISTORY If Living If Deceased Age Health Age at death Cause Father: _____________________________________________________________________________ Mother: _____________________________________________________________________________ Brother/Sister: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Husband/Wife: _______________________________________________________________________ Children _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
*2-32767*
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Do you feel that you have been abused, neglected or exploited by someone close to you? Yes No Do you need help with personal/financial, social problems, obtaining your medications or supplies? Yes No
Completed by: _________________________________ Relationship to patient: ___________________ Form Reviewed by: _____________________________ Date/Time: _____________________________
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__________________________________________________________________________
DESIGNATION OF PERSONAL REPRESENTATIVE:
As a patient, you may designate one or more personal representatives. A personal representative may receive Protected Health Information (PHI) about you. PHI includes information about your current medical condition and diagnosis, treatment and prognosis, and billing and payments. Personal representatives will not have access to PHI in the periods that are between treatments or admissions. My personal representative(s) is listed below and my signature of approval. A personal representative may be a spouse, relative, domestic partner, or friend. You can remove or add personal representatives at any time, including during treatment or upon another admission to a GHS facility. _____ (initial) I (Patient) do not wish to designate a personal representative. I understand that the hospitals healthcare team may designate an interim personal representative, if designating a personal representative will expedite or enhance my care as a patient.
________________________________________________________ Patient or Authorized Representative Signature ______________________________________ GHS Representative Name __________________________ Department
*1-32434*
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*2-1834*
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aa.
information about the hospitals mechanism for the initiation, review and resolution of patient complaints including the right to: 1. access an internal grievance process through contact with the Patient Representative Department of the hospital, or 2. seek external review of your concerns by contacting either the Department of Human Resources Office of Regulatory Services at Two Peachtree St., NW, Atlanta, Ga. 30303-3142, or by phone at 404-6575700 or the Joint Commission at 1-800-944-6610.
If you have any questions or concerns regarding Patient Rights and Responsibilities or special assistance, contact the Patient Representative Department at 678-312-4399 or 678-312-1000.
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IntegratedCancerCenterwithGwinnettMedicalCenter Whyarewedoingthis? Thisrelationshipisamajorstepincreatingamorecomprehensivecancerprogramforourcommunity.We wanttomakeitaseasyandconvenientaspossibleforyoutogetthecancercareyouneed.Thankstoour relationshipwithGwinnettMedicalCenter,wearenowabletoofferallpatientsinfusion/injectionservicesat ourofficelocations.So,ifyoureceivedinfusiontreatmentsatahospitalinthepast,youcannowreceive theseservicesinouroffice.Thischangewillmostlikelysaveyousometime,andyoullbeabletoreceivecare fromthepeoplewhoyouhavecometoknowandtrust. Whatschanging? Asmentionedabove,thankstotherelationshipbetweenSuburbanHematologyOncologyAssociatesand GwinnettMedicalCenter,wecannowofferinfusion/injectionservicesatourspacious,modernfacilitiesin Lawrenceville,DuluthandSnellville.Inrecognitionofthestrongtiesbetweenourtwoorganizations,thename oftheinfusioncenteratSuburbanHematologyOncologyAssociateswillnowbecometheCenterforCancer Care,aserviceofGwinnettMedicalCenter. Whatisntchanging? Youwillcontinuetoseethesameexperiencedphysiciansandstaffthatyouhaveinthepastandour commitmenttoprovidingqualitycareinacomfortable,compassionatesettingremainsunchanged.Wewill continuetotreatyounotjustasapatient,butasaperson,andwewillworkwithyoutoproducethebest possibleoutcomes. Whatsmore,ifyoushouldrequireinpatientcare,youwillhaveconvenientaccesstotheexcellentdiagnostic andinpatientservicesatGwinnettMedicalCentershospitalsinLawrencevilleandDuluth. Wewillalsotrytotakesomeofthestressoutofwhatcanbeaverychallengingtimeinyourlife.Wellhelp youtounderstandyourtreatmentoptionsandtogetthecareyouneed,regardlessofyourfinancialsituation includingconnectingyouwithoutsideresourcestohelpyoucoverthecostsoftreatment. Howwillthecostofmycarebeaffected? Justasyourtreatmentisunique,soisyourfinancialsituation.Ourbenefitscounselorscanworkwithyouto determineyourspecificresponsibilitiesandtheresources,includingyourinsuranceprovider,tohelppayfor thecostofyourcare. CanIcontinuetohavemylabworkhere? Yes.Wenowhavetheabilitytoperformmoretestingwithinourfacility.
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CanIcontinuetoseemysamedoctor? Yes.Youwillcontinuetoseethesamephysician.Therewillnotbeanychangestoyourtreatmentpathasa resultofthispartnership.Onlyyouandyourdoctorwilldeterminewhatcareisappropriate. Willmyinsurancecopaymentandcoinsuranceamountschange? TheCenterforCancerCarenowbillsunderGwinnettMedicalCenterstaxidentificationnumber.Thetax identificationnumberisusedbyinsurancecompaniestodiscoverthespecificcontractwithhealthcare providers.Anyplanthehospitaliscontractedwithwillbethesameasthecenter.Everyplanisdifferent;the policytermsareusedtodetermineinsurancepaymentamounts,contractualamounts(theportionyour doctorandcenteragreetoaccept),andpatientresponsibilityamounts.So,youshouldanticipateapossible changeinyourcopaymentsandcoinsuranceamounts.Ourbenefitscounselorsareheretohelpyou understandyourinsurancebenefitsandprovidepaymentoptions. HowwillIknowwhatIowe? Ourbenefitscounselorswillverifyyourbenefitsanddeterminewhatwillbepaidbyyourinsurancecompany andprovideanestimateofwhatamount,ifany,youwillowe.Wewillexplainyourbenefitcoveragedetails andanyamountdueoncewediscoveryoureindividualplan. Insomecaseswewillnotknowbeforeyourvisitexactlywhattreatmentyoullbereceiving.Ifanamountdue cannotbedeterminedwewillgiveyouthebasicpolicyinformationsuchasdeductiblesandmaxoutofpocket portionsasastartingpoint.Wewillfileyourinsuranceandbillyouforanyremainingbalance. WillthebillcomefromGwinnettMedicalCenter? Thestaffthathasbeenfilingyourinsuranceclaimswillcontinuetoprepareandsubmityourclaimstoyour insurancecompany.Ifthereisaremainingbalance,wewillmailyouastatement.Thenameonthestatement willbeTheCenterforCancerCare,aserviceofGwinnettMedicalCenter.Weareavailabletodiscuss statementswithinthecenteronfollowupvisitsbyourassociates.Thosebillscanonlybediscussedwithinthe Center.Mainhospitalassociateswillnothaveyourstatementinformationsoitsimportanttocallthe numberslistedonthestatementifyouhaveaquestionorspeaktousinperson. IhaveMedicare,willIexperienceanychanges? Youwillhaveanewformtoreadandsign.Itpertainstoyouacknowledgingthatyouarebeingtreatedata hospitalbasedcenterwhichmayincreasethecoinsuranceamountyouowe.TheformisaCMSrequirement. Iamuninsuredwilltherestillbeassistanceandfinancialresourcesavailabletome? Yes.Ourbenefitcounselorswillcontinuetohelpyoufindtherightfinancialresourcesthatfityourfinancial situation.Also,thehospitalfinancialassistanceprogramisavailable.
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