POLICIES & PATIENT FORMS

We strive to offer the best services and care for each patient in a timely manner. The “policies or rules” listed here are essential and necessary to efficiently manage a busy clinic. We sincerely appreciate your cooperation and understanding in our efforts to provide quality health care to our patients.

• Walk-ins are welcome. Walk-in patients will be seen, but they may experience longer wait-time since patients with appointments will be seen first unless a walk-in patient is experiencing a medical emergency. Patients are encouraged to make appointments.
• We understand that appointments sometime need to be changed, so we ask that you call at least 24 hours in advance if you cannot keep your scheduled appointment to avoid No Show Fee of $35.00. Any advance notice of a cancellation will be helpful.
• We accept following forms of payment from New Patient – Credit Card, Debit Card or Cash. No Checks accepted. For Existing Patients, no checks above $50.00 accepted. Any returned check is subject to unpaid balance plus $25.00 returned check fee. We apologize for any inconvenience.
• As a courtesy to our patients, we offer reasonable payment plan arrangements to those patients who might require assistance. All amounts due per payment plan will be automatically drafted on dates agreed on payment plan.
• Failure to pay patient account balance in time will result in your account be transferred to our collection agency. Once account transferred to a collection agency, you will be responsible for additional 50% of unpaid balance to meet the costs incurred to get payment.
• Please read our Prescription Refill Policy We require 4 days minimum to process prescription refill request. We will not entertain same day or walk-in refill request. Non-controlled/non-narcotics prescriptions require 3 months follow up. Controlled substances/narcotics prescriptions require 30 days follow up. Prescriptions written by another doctor CANNOT be refilled without an appointment.
• For other after-hours emergencies call us at 919-348-0805. Please restrict all after hour calls to TRUE emergencies. There will be a $25.00 charge for non-emergency calls. The provider on-call cannot call in prescriptions after hours.
• To curb the Emergency room cost, most insurance plans encourage doctor’s office to offer extended hours to meet patient needs. The additional operating cost for physician’s office is reimbursed by billing Evening/weekend/Holiday code 99050/99051 along with your visit codes to insurance companies. Most insurance companies recognize this billable charge and will provide full or partial reimbursement. You may be responsible for only the allowable portion of this charge in the event that your insurance company assigns it to your deductible or coinsurance (in most cases up to $35.00).
• Medical Record Fee- We are pleased to provide you with your medical record via our Electronic Health Record system to Patient Portal free of cost. But should you need them mailed, we will bill you a reasonable fee for the preparation and/or the photocopying of the materials per NC Statue 90-411.
• Due to recent changes in insurance payment policy, they require your wellness care and your illness/follow up care to be addressed in two separate visits. If you do not adhere to this policy, you will be subject to the charges NOT covered by your insurance carrier. Please read our Same day Wellness/ Sick policy.
• Please note, sports/camp/daycare/employment physicals are no longer covered by Insurance companies due to failure to prove medical necessity. You will be responsible for these services at a flat rate.

Please email your ID & Insurance Card (front & back) to tricityfamilymedicine@myupdox.com