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| Phone: (512) 977-8300 |
Our office participates with many health insurance companies in the Austin
area. We encourage you to be an informed consumer by understanding your
coverage, how to access information from your carrier, and which ancillary
providers, e.g. lab, and x-ray facilities, participate with your plan. You will be
asked to present your insurance card(s) and a valid driver’s license or
identification card at your initial visit to our office. When there are changes,
either in demographics or insurance coverage, it is your responsibility to
inform the office and supply supporting documentation.
MEDICARE: If you are a Medicare beneficiary, you may be asked to sign an
Advance Notice of Benefits (ABN) for services which may not be covered by
Medicare, but are considered medically necessary by your physician. When
this occurs, you will be informed about the potential charges which you may
incur should Medicare deny payment of these services. There are some
preventative services which your physician may recommend to establish a
baseline, but are non-covered services by Medicare, e.g. routine physical
examination, certain screening tests and inoculations. If you desire to have
these services performed, these will be at your own expense and payment is
required at the time of service.
MEDICAID: Our office does NOT participate in this program. Therefore, we
cannot bill Medicaid for any services provided by this office. If you choose to
see one of our providers, our expectations are the same as those for Self-Pay
Patients.
SELF-PAY PATIENTS: Self –Pay Patients will receive a discount on physician
services only. Other services provided within the office will NOT be
discounted. Payments are required at the time services are received.
THERE IS NO EXCEPTION TO THIS POLICY.
THIRD PARTY PAYORS: Patients who are established in our practice may
encounter situations in which they may suffer injury or illness in which a third
party may be liable (e.g. auto accident). As a courtesy to our patients, we may
elect to treat a patient for any such circumstance if a valid third party payor can
be contacted who will guarantee payment for such services. It is the patient’s
responsibility to pay for such services which may be later denied or deemed
unnecessary by any third party.
WORKERS COMPENSATION: Dr. Toupin does not participate in the State of
Texas or Federal Workers Compensation programs. It is the patient’s
responsibility to contact his/her employer to find appropriate medical care. All
injuries deemed work-related will be directed to the patient’s employer for
determination of eligibility for Workers Compensation.
DEMOGRAPHICS:
During registration it is mandatory that a copy of your driver’s license (or legal
identification card) and a currently active insurance card be provided for
identification in your chart. It is also required that we obtain additional
personal information including your social security number, physical
addresses and phone numbers. It is imperative that you update your health
insurance information with our office as soon as possible so as to avoid
improper billing and unnecessary late fees. In addition, we request the
allowance of a personal photograph at the time of registration to insure the
accuracy of your identification.
FINANCIAL POLICY: We require that any applicable deductible, co-insurance
or co-payment be paid at the time services are rendered. Payment may be
made by cash, authorized check, Visa or MasterCard. There is a $30.00 fee
for returned checks. THERE IS NO EXCEPTION TO THIS POLICY.
AFTER HOURS CALLS: Calls made to the office after hours will be redirected
to a paging service. Messages may be left at the paging service which will be
forwarded to the Doctor’s office. A doctor on call can be reached for
emergencies. This service is not intended for non-emergent calls such as
prescription refill requests, appointment requests, and other services
provided routinely during office hours. The office reserves the right to charge
your insurance for phone or internet consultations.
REFERRALS: Patients with HMO insurances, including some Medicare
Advantage Plans require authorizations prior to appointments. We ask that
these requests be made at least 2 business days prior to any scheduled
appointment to a referred specialist.
HMO INSURANCES: Patients with HMO insurance plans must choose Dr.
Toupin as their primary care provider prior to their appointment in our office in
order to allow insurance coverage of the fees of the initial office visit. It is the
responsibility of the patient to implement this designation at least one day
prior to their office visit.
CANCELLATIONS: When you are unable to keep an appointment, please
notify our office promptly. We will gladly try to change appointment dates and
times to accommodate your schedule if you provide a 24 hour notice prior to
your scheduled appointment. Our office reserves the right to charge a $50.00
no show fee for failure to provide 24 hour notice of appointment
cancellations. The no show fee must be paid prior to any future
appointments.
As a courtesy, appointment reminder calls will be made to you through an
automated calling service at least 24 hours prior to your appointment. You
will have the opportunity to confirm or cancel your appointment through the
use of this service. However, it is your responsibility to cancel any scheduled
appointment as this reminder call cannot be guaranteed to contact you prior
to your appointment.
RELEASE OF INFORMATION: There are situations in which we are permitted
to disclose or use your medical information without your written authorization
or an opportunity to object. These situations are mandated by federal, state
and/or local government. In other situations, we will ask for your authorization
before using or disclosing any protected health information (PHI). If you
choose to sign an authorization to disclose information, you can later revoke
that authorization in writing to stop future uses and disclosures. However,
any revocation will not apply to disclosures or uses already made or that rely
on that authorization. Please note that we cannot release information about a
spouse or family member without an authorization to do so.
Your records are maintained within an electronic medical record (EMR) that is
secure and compliant with the Health Insurance Portability and Accountability
Act (HIPAA). If we request and obtain records from physicians who have
treated you previously, appropriate documents will be scanned into our
system and the hard copies will be destroyed. If hard copies of the
information are required, we reserve the right to assess a fee to recoup the
associated costs of handling your request as allowed by law.
REPORTS: A minimum fee of $15.00 will be charged for the completion of
forms and medical reports. A fee of $25.00 will be charged for detailed forms
such as FMLA, health insurance questionnaires, disability forms. The
assessed fee must be paid before we can release the requested information.
PRESCRIPTION REFILLS: We ask that refill requests be made at least
seven days in advance of your needing the medication refilled. Refill
requests MUST BE MADE by contacting your pharmacy. Refill requests will
be faxed by your pharmacy to our office. Most pharmacies will have our fax
number on file; if not, you may ask them to fax the request to 512-977-8301.
This would include the transfer of any other prescribing physician to our office
If your prescriptions are being submitted to a mail order pharmacy, please
allow one week for the processing of your request by our office. For patients
requesting a prescription which requires insurance authorization, please
allow one week for processing all requests. If your request cannot be
processed or is denied by your insurance, then it is your responsibility to self
pay for the prescription or contact our office during regular office hours to
request assistance in finding an alternative medication. Refills may be given
to patients seen within a six month period. If your last appointment was more
than six months prior to your request, our physicians MAY authorize a one
time refill for one month. An office visit will be required for future refills.
NON-COVERED ITEMS: Certain office medical procedures may not be
considered covered benefits by your insurance company. Such services
typically include travel vaccinations, physical examinations, screening lab
tests or other procedures (e.g. cosmetic). It is the patient’s responsibility to
pay for such items if denied by your insurance company. All Medicare
patients are required to be informed of such items at the time of service and
give consent to the fact that the service may or may not be covered.
ADVANCE DIRECTIVES: For your convenience our office maintains Texas
Advance Directives, Durable Power of Attorney For Healthcare and Do Not
Resuscitate Forms on file. Please request these forms or discuss their
relevance during your office visit.
Office Policy 08/07/2007
Revised 04-01-2008
Leo Toupin, M.D.
area. We encourage you to be an informed consumer by understanding your
coverage, how to access information from your carrier, and which ancillary
providers, e.g. lab, and x-ray facilities, participate with your plan. You will be
asked to present your insurance card(s) and a valid driver’s license or
identification card at your initial visit to our office. When there are changes,
either in demographics or insurance coverage, it is your responsibility to
inform the office and supply supporting documentation.
MEDICARE: If you are a Medicare beneficiary, you may be asked to sign an
Advance Notice of Benefits (ABN) for services which may not be covered by
Medicare, but are considered medically necessary by your physician. When
this occurs, you will be informed about the potential charges which you may
incur should Medicare deny payment of these services. There are some
preventative services which your physician may recommend to establish a
baseline, but are non-covered services by Medicare, e.g. routine physical
examination, certain screening tests and inoculations. If you desire to have
these services performed, these will be at your own expense and payment is
required at the time of service.
MEDICAID: Our office does NOT participate in this program. Therefore, we
cannot bill Medicaid for any services provided by this office. If you choose to
see one of our providers, our expectations are the same as those for Self-Pay
Patients.
SELF-PAY PATIENTS: Self –Pay Patients will receive a discount on physician
services only. Other services provided within the office will NOT be
discounted. Payments are required at the time services are received.
THERE IS NO EXCEPTION TO THIS POLICY.
THIRD PARTY PAYORS: Patients who are established in our practice may
encounter situations in which they may suffer injury or illness in which a third
party may be liable (e.g. auto accident). As a courtesy to our patients, we may
elect to treat a patient for any such circumstance if a valid third party payor can
be contacted who will guarantee payment for such services. It is the patient’s
responsibility to pay for such services which may be later denied or deemed
unnecessary by any third party.
WORKERS COMPENSATION: Dr. Toupin does not participate in the State of
Texas or Federal Workers Compensation programs. It is the patient’s
responsibility to contact his/her employer to find appropriate medical care. All
injuries deemed work-related will be directed to the patient’s employer for
determination of eligibility for Workers Compensation.
DEMOGRAPHICS:
During registration it is mandatory that a copy of your driver’s license (or legal
identification card) and a currently active insurance card be provided for
identification in your chart. It is also required that we obtain additional
personal information including your social security number, physical
addresses and phone numbers. It is imperative that you update your health
insurance information with our office as soon as possible so as to avoid
improper billing and unnecessary late fees. In addition, we request the
allowance of a personal photograph at the time of registration to insure the
accuracy of your identification.
FINANCIAL POLICY: We require that any applicable deductible, co-insurance
or co-payment be paid at the time services are rendered. Payment may be
made by cash, authorized check, Visa or MasterCard. There is a $30.00 fee
for returned checks. THERE IS NO EXCEPTION TO THIS POLICY.
AFTER HOURS CALLS: Calls made to the office after hours will be redirected
to a paging service. Messages may be left at the paging service which will be
forwarded to the Doctor’s office. A doctor on call can be reached for
emergencies. This service is not intended for non-emergent calls such as
prescription refill requests, appointment requests, and other services
provided routinely during office hours. The office reserves the right to charge
your insurance for phone or internet consultations.
REFERRALS: Patients with HMO insurances, including some Medicare
Advantage Plans require authorizations prior to appointments. We ask that
these requests be made at least 2 business days prior to any scheduled
appointment to a referred specialist.
HMO INSURANCES: Patients with HMO insurance plans must choose Dr.
Toupin as their primary care provider prior to their appointment in our office in
order to allow insurance coverage of the fees of the initial office visit. It is the
responsibility of the patient to implement this designation at least one day
prior to their office visit.
CANCELLATIONS: When you are unable to keep an appointment, please
notify our office promptly. We will gladly try to change appointment dates and
times to accommodate your schedule if you provide a 24 hour notice prior to
your scheduled appointment. Our office reserves the right to charge a $50.00
no show fee for failure to provide 24 hour notice of appointment
cancellations. The no show fee must be paid prior to any future
appointments.
As a courtesy, appointment reminder calls will be made to you through an
automated calling service at least 24 hours prior to your appointment. You
will have the opportunity to confirm or cancel your appointment through the
use of this service. However, it is your responsibility to cancel any scheduled
appointment as this reminder call cannot be guaranteed to contact you prior
to your appointment.
RELEASE OF INFORMATION: There are situations in which we are permitted
to disclose or use your medical information without your written authorization
or an opportunity to object. These situations are mandated by federal, state
and/or local government. In other situations, we will ask for your authorization
before using or disclosing any protected health information (PHI). If you
choose to sign an authorization to disclose information, you can later revoke
that authorization in writing to stop future uses and disclosures. However,
any revocation will not apply to disclosures or uses already made or that rely
on that authorization. Please note that we cannot release information about a
spouse or family member without an authorization to do so.
Your records are maintained within an electronic medical record (EMR) that is
secure and compliant with the Health Insurance Portability and Accountability
Act (HIPAA). If we request and obtain records from physicians who have
treated you previously, appropriate documents will be scanned into our
system and the hard copies will be destroyed. If hard copies of the
information are required, we reserve the right to assess a fee to recoup the
associated costs of handling your request as allowed by law.
REPORTS: A minimum fee of $15.00 will be charged for the completion of
forms and medical reports. A fee of $25.00 will be charged for detailed forms
such as FMLA, health insurance questionnaires, disability forms. The
assessed fee must be paid before we can release the requested information.
PRESCRIPTION REFILLS: We ask that refill requests be made at least
seven days in advance of your needing the medication refilled. Refill
requests MUST BE MADE by contacting your pharmacy. Refill requests will
be faxed by your pharmacy to our office. Most pharmacies will have our fax
number on file; if not, you may ask them to fax the request to 512-977-8301.
This would include the transfer of any other prescribing physician to our office
If your prescriptions are being submitted to a mail order pharmacy, please
allow one week for the processing of your request by our office. For patients
requesting a prescription which requires insurance authorization, please
allow one week for processing all requests. If your request cannot be
processed or is denied by your insurance, then it is your responsibility to self
pay for the prescription or contact our office during regular office hours to
request assistance in finding an alternative medication. Refills may be given
to patients seen within a six month period. If your last appointment was more
than six months prior to your request, our physicians MAY authorize a one
time refill for one month. An office visit will be required for future refills.
NON-COVERED ITEMS: Certain office medical procedures may not be
considered covered benefits by your insurance company. Such services
typically include travel vaccinations, physical examinations, screening lab
tests or other procedures (e.g. cosmetic). It is the patient’s responsibility to
pay for such items if denied by your insurance company. All Medicare
patients are required to be informed of such items at the time of service and
give consent to the fact that the service may or may not be covered.
ADVANCE DIRECTIVES: For your convenience our office maintains Texas
Advance Directives, Durable Power of Attorney For Healthcare and Do Not
Resuscitate Forms on file. Please request these forms or discuss their
relevance during your office visit.
Office Policy 08/07/2007
Revised 04-01-2008
Leo Toupin, M.D.
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| Office Policies Page |
Leo Toupin MD PA
Our goal is to provide quality,
efficient and cost effective
primary patient care.
efficient and cost effective
primary patient care.
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| Leo Toupin, M.D., P. A. . OFFICE POLICIES |