Ashburn Sterling Internal Medicine and Pediatrics
Lansdowne Medical Pavilion
19415 Deerfield Ave, Suite 213
Lansdowne, Virginia 20176
(703) 729-9220

 

Appointments

Please click on "On-Line Access" to request your appointment on line or call (703) 729-9220 for appointments. For advanced registration, please print out Registration Form, complete and bring with you. Same day appointments usually available!

If you have any questions, please feel free to contact us during normal office hours.

Patient Registration Form - Ashburn Sterling Internal Medicine and Pediatrics

Patient's Name (Last) ______________________________ First_______________________________ Middle______________________
Parent's Name (if minor)____________________________________________________________________________________
Address_________________________________________________________________City,____________________________
State____________________ Zip Code_________________ Sex: M/F__________

Social Sec. #____________________________________ Birth date ____________________

PLEASE PROVIDE ALL OF THE FOLLOWING: COMMUNICATION IS A VITAL PART OF YOUR HEALHCARE
EMAIL address:______________________________
Home Phone___________________ Cell Phone ___________________Work Phone (parents or spouse)________________
Patient Employer______________________________________________________ Referred By:________________________
EMERGENCY CONTACT ___________________________________________Phone Number________________________

Responsible Party
Policy Holder's Name______________________________________________________________________________________
Address_______________________________________________ City, State, Zip______________________________________
Patient Relation to Guarantor____________________________ Guarantor Employer____________________________________
Home Phone_________________________ Cell Phone_______________________ Employer's phone_____________________
Employer's address_______________________________________ City, State, Zip_____________________________________
Policy Holder's SS#_________________________________________Birthdate_____________________Sex________________
Primary Insurance: Effective Date:________________

Name of Insurance Company____________________________________________Policyholder__________________________
Pt Relation to Policyholder_______________________ Policy Number_____________________ Group Number______________
Insurance Co. Address_____________________________________________________________________________________
Insurance Co. Phone Number ____________________________Policyholder's Birth date _______________Sex_____________
Secondary Insurance: Effective Date:________________

Name of Insurance Company_____________________________________________Policyholder_________________________
Pt Relation to Policyholder_____________________Policy Number______________________Group Number_______________
Co. Address______________________________________________________________________________________
Insurance Co. Phone Number_____________________________Policyholder's Birthdate_________________Sex____________

I, the undersigned, hereby consent to and authorize the administration and performance of all treatments, the administration of any needed anesthetics, the performance of such procedures as may be deemed advisable in the treatment of this patient, the use of prescribed medication; the performance of diagnostic procedures,; the taking and utilization of cultures and performance of other medically accepted laboratory test, all of which the judgement of the attending physician or their designees, may be considered medically necessary or advisable.

I fully understand that this consent is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in force until revoked in writing.

I hereby authorize Ashburn Sterling Internal Medicine and Pediatrics to release medical information to any of my physicians or insurance companies that may be pertinent to my case. I hereby authorize payment directly to Ashburn Sterling Internal Medicine and Pediatrics of benefits otherwise payable to me. I hereby, authorize to release of my medical records to third party insurers or other authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided. I understand that I am financially responsible for charges not covered by this authorization. A photocopy of this authorization shall be considered as valid as the original. "Further, I acknowledge that I am indebted for past due charges and I understand that I am financially responsible for those charges also" I understand it is my responsibility to cancel my appointment at least 24hours in advance. A charge will be assessed for missed appointments where the 24hour notification was not given.

Medicare patients: I authorize Ashburn Sterling Internal Medicine and Pediatrics to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to Ashburn Sterling Internal Medicine and Pediatrics.

In accordance with the provisions of Section 32.1-45.1 of the Code of Virginia, (whenever any health care provider, or any person employed by or under the direction and control of a health care provider, is directly exposed to body fluids of a patient in a manner which may, according to current guidelines of the Centers of Disease Control, transmit human immunodeficiency virus), the patient whose body fluids were involved in the exposure shall be deemed to have consented to testing for infection with human immunodeficiency virus.

If there is an exposure, and the patient's test is positive, the attending physician will notify the patient, any person exposed, the Virginia Health Department and appropriate counseling will be offered.

Patient Responsibilities and Office Policies: It is the patient responsibility to know your insurance policy and understand your benefits. It is the patient responsibility to make sure specific laboratory, outpatient radiology facility, inpatient radiology facility or consultant physician accepts your insurance. It is the patient responsibility to understand your policy benefits and know what is covered and not covered.

As a courtesy to patients with later appointments our office adheres to a late policy of fifteen minutes. If a patient is late for an appointment 15 minutes or greater, they may be asked to reschedule.

Our office requires 24 hours notice for cancellation. If an appointment is not cancelled, the patient will be charged a $45 "no show" fee*. If you believe you have been charged a "no show" fee in error, please address a written request for review to Dr. Abedin within 30 days.

Referrals require up to 72hours to process. Your referral can be picked up or faxed. If you choose to pick up your referral, you will be called when it is ready. Referrals can only be done on the same day for medical emergencies, otherwise a charge will be assessed. Information can also be submitted at our Referral Request Link. (Click Contact Us on our website)

This office will file all primary insurance claims. Secondary claims will be filed for Medicare and Medicaid patients. Secondary claims for other carriers will be mailed to the patient with a copy of the primary carrier's explanation of benefits.

After hours calls to our on-call physicians are reserved for emergencies only. If you feel you need to go to the emergency room after our office hours for anything that is not obviously life threatening you may first need to contact the on call physician for authorization. Failure to do so may result in a rejection of payment from your insurance company.

Prescription refills require 24 hours to be filled. Please call your pharmacy and request that they fax us a refill request. (Alternatively Click Contact Us on our website)

Billing Policy

Medical records may take up to 14 days to be copied. ASIMPEDS does charge for copies of medical records. This fee and written authorization are required prior to copying.

Co-payments must be paid prior to each visit. This is required in the terms of your contract with your insurance company. Forms of payment accepted are cash, VISA, MasterCard, money order or check.

Patients must present with appropriate insurance information or the patient will be considered self-pay for the full cost of the visit. Patients with coverage requiring a Primary Care Physician must have an appropriate physician on their card at the time of service. If any of the above information is missing, the patient must obtain it within 20 minutes of the scheduled appointment time or sign waiver indicating financial responsibility for the visit.

All patients require appointments to be seen. Same day appointments are available for urgent patients and situations.

Patient bills are mailed once a month. Payment in full is due within 30 days. Balances over $50 can be paid at a minimum of 20% of the total account balance per month. A $20 late fee and finance charges will apply to all accounts when the minimum amount due is not paid within 30 days. The patient agrees to pay all cancelled appt fees, bounced check fees, finance charges, court fees, collection fees, and attorney fees accrued in collecting overdue debts. Payment plans are available on current accounts. Payment arrangements must be made with the Billing Manager prior to service for overdue accounts. Discounts are only available to patients who choose to provide proof of financial hardship in the form of a tax return or a statement of disability income. Hardship information must be updated with the Office Manager annually. Please address concerns regarding bills to the Billing Department or Billing Manager.

Accounts greater than 60 days past due are eligible for collection activity. The patient will be responsible for all collection fees, court fees, and attorney fees incurred. All accounts placed in collections will be required to choose a new Primary Care Physician. This policy applies to the patient as well as the patient's immediate family/ responsible party.

Signature______________________________________________

Notice of Privacy Practices: Description of Medical Information Disclosure and Patient Access Information. Please Review Carefully.
Ashburn Sterling Internal Medicine and Pediatrics will use your health information for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of the healthcare that we provide to you. Continuity of care is part of treatment and your records will be shared with other providers and facilities to whom you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. Your email may be used for regular practice bulletins, conveyence of billing reminders, and health information and reminders.

Ashburn Sterling Internal Medicine and Pediatrics may use or disclose identifiable health information about you without your authorization for the following reasons. Public Health Requirements, auditing purposes, research studies, quality assurance, and emergencies may result in the release or sharing of your medical information. We also provide information when required by law, such as for law enforcement. In any other situation, we will ask for your written authorization before disclosing any specific health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future disclosures.

Ashburn Sterling Internal Medicine and Pediatrics may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time or visit our website: www.myhealthcare.org. For more information about our privacy policies please do not hesitate to ask any member of our staff.

In most cases, you have the right to review your health information with one of our physicians or have it sent to another provider with whom you may review your medical record. The charge for this service is 25 dollars. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, continuity of care with a practitioner or facility to whom you have been referred, or administrative purposes other than when you explicitly authorized it. Of you believe that information in your record is incorrect or important information is missing, you have the right to request that we correct the existing information or add the missing information.

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact any member of our staff. You may also send a written complaint to the U.S. Department of Health and Human Services. We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this consent, and obtain acknowledgement of receipt of this notice.

Access and Amendment Policy
Ashburn Sterling Internal Medicine and Pediatrics will give the patient to review with a physician their health information whether we or our business associates hold that information and whether or not we were the source of the information. Exceptions to this access occur rarely, such as when the information is deemed dangerous. If we feel we need to deny access, we will provide an explanation. Sometimes the patient can contest this denial, and then we will have a third party review the situation. The patient may request access and review with our physicians or request it be sent to another physician to review with the patient. We will keep a record of the request in the patient's chart. We typically require 30 days in which to comply with this request. The cost to the patient will be 15 dollars.

The patient may request, in writing, that we amend our records about the patient. We will enter the patient's written request into the medical record, and reply within 60days. We may deny the patient request if we were not the originators of the information or we believe the information accurate. If we make an amendment, we add a note to the record to indicate the change but do not delete the original information. If we deny the patient request, then we will provide an explanation. The patient may contest our denial and among other things we will document the patient concerns in the medical record.

Accounting and Restrictions Policy
Disclosures: The patient has a right to receive an accounting of certain disclosures of the patient's protected health information that we made in the six years prior to the date of the patient's request. The patient's request must be in writing and will be entered into our medical record. We have 60days to respond. Our accounting will be in writing and include dates, contents, and purpose of disclosure. In any 12month period we will provide one accounting at no cost. Disclosures for treatment, payment, or healthcare operations are not included in this accounting; nor are those made with patient authorization. Exceptional disclosures, such as a diagnosis of active tuberculosis and report to the public health agency, or a gun shot wound to the police will be accounted. We will accommodate a request that we communicate with the patient my alternative means, if we can practically implement such an alternative. The patient is not required to explain why he or she wants such an alternative means of communication. Our agreement with the patient for an alternative communication channel will be documented and included in the patient's medical record.

Results Policy and Patient Responsibility
It is our policy to discuss your lab and radiology results at your follow up appointment or by phone. If you have not had your follow up appointment or received a phone call please call us so that we may track down those results for you. Results may also be conveyed via email. It is your responsibility to make sure that your contact information including your address and phone number are current. It is your responsibility to make and keep your follow up appointments, referrals and ancillary testing.

I have reviewed my PATIENTS RIGHTS & RESPONSIBILITIES, PRIVACY POLICIES, BILLING, AND ACCESS & AMENDEMENT POLICIES. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Patient's Signature (or responsible party)________________________________________________ Date__________

EZPAY service (use to prevent finance charges)

In order to provide high quality services it is important to keep medical administrative costs to a minimum. In an effort to make collections of balances that are due easier for our patients as well as the staff, we are pleased to introduce EZ PAY. EZ PAY is a safe (encrypted) way to your store your credit card information so that it may be used to pay for balances due AFTER your insurance company has paid their portion. The amount charged to your credit card will be $50. As your information is encrypted it can not be viewed at anytime and remains confidentially stored in the database. Any balances that are overdue will accrue finance charges and be turned over to collections. Your participation in this program will prevent unnecessary costs and financing charges, a 25% finance charge will be assessed on all balances not paid within 30days. If you have any questions, feel free to ask the receptionist or billing staff for more information.

Please Circle Mastercard Visa

I, the undersigned, understand that if my account becomes more that 90 days delinquent, and my account goes into collections, I am responsible for paying all collection fees, in addition to finance charges, and the principal amount. I understand that if my phone numbers or any other means of contact change, I am responsible for notifying this office in a timely manner so that collections of any balances may be made.

Signature____________________________________________________________

EZPAY Service Ashburn Sterling Internal Medicine and Pediatrics

In order to provide high quality services it is important to keep medical administrative costs to a minimum.

We are pleased to provide E-Z Pay an easy (encrypted) way to store your credit card information so that it may be used to pay for your copay fees and/or to pay balances due AFTER your insurance compay has paid their portions ( patient responsibilites or deductibles – finance charges at 25% will be assessed on all balances not paid within 30 days) . As your information is encrypted it cannot be viewed at anytime and remains confidentially stored in the database for one year. At that time you will be asked to reregister your information. Mastercard and/or Visa, including flex spending debit cards,are accepted.

Whenever a payment is charged to your credit card you will receive a mailed copy of the receipt for your records. With your permission you can automatically pay co-pays, prevent unnecessary costs and financing charges and you will be eligible for additional services provided by this office that may require out of pocket charges. I, the undersigned ACCEPT participation in the available EZ PAY service.

Maximum amount charged to your credit card will be $100 unless otherwise specified or approved by participant. By giving your credit card information, you have agreed to pay annual fee’s and keep your credit card on file.

Signature_______________________________________________________ Date:_______________

Please provide your credit card information to the receptionist or billing staff

Visa or Mastercard # ____________________________________ Exp. Date:_____________

Cardholder Name:_______________________________________

Maximum Withdrawal from credit card account $________________ ________(initial)

Premier Membership Fee - $30.00/year administrative fee will be deducted from your account at time of enrollment and annually.

Participating Members: _______________________________________________________________________________________________________________________________________________

______________(initial)

****Annual enrollment fees are subject to changes annually.

JMC 5/17/07, Rev 6/13/07jmc rev 7/3/07 tlz rev. 7/23/07tlz