Mark L Thornton MD FACP Execudoc Inc Membership Agreement Thank by johnrr1


									Mark L. Thornton, MD, FACP/Execudoc, Inc. Membership Agreement
Thank you for joining me in my new practice that provides services to you as a patient and a partner in your health care services in a unique and personalized manner. By agreeing to become a member in Dr. Thornton’s practice you become entitled to the following services: • • • • • • • • • • • Individualized care in a relaxed setting without undo time constraints Same Day or next day preferred appointments Annual Physical Exam Comprehensive preventive care plan and lifestyle planning Physician Available 24/7 Direct access through voice, pager, cell phone, fax and email Prescription facilitation Coordination of care with specialist Referral coordination Claims facilitation Travel medicine services

In addition to these services Dr. Thornton is accepting the responsibility of being your Personal Physician. As a member you have the following responsibilities: • • • • Provide current and accurate information Provide a credit card for fee’s associated with services provided and/or annual membership fee’s Become a partner in the health care services being provided Enjoy the benefits of the practice

Annual Fee Schedule for Membership Adult Adult and Spouse Two Adults and One Child (between the ages of 15 and 25) Each additional Child $1,500 $2,850 $3,600 $750

Membership fee cannot and does not apply to any deductibles, co-payments, or coinsurance for any insurance, Medicare and Medicaid.

I, ________________________________, agree to become a member of the medical practice of Mark L. Thornton, MD, FACP, and agree to the annual membership fee in return for Dr. Mark L. Thornton becoming my Personal Physician.

____________________________________________________ Signature and Date

Mark L. Thornton, MD, FACP/Execudoc, Inc. Patient Registration Welcome to our office, in order to serve you properly we will need the following information. (Please Print or Type) All information will be strictly confidential
Patients Name: (Last, First) Sex Birth Date ______/______/______ F M Age___________________ Residence Address City State Zip Home Phone: Widowed [ ] Divorced [ ] Patient Social Security # Single [ ] Married [ ] Marital Status

Email Address

Cell Phone

Work Phone

Person Financially responsible for this account (Last, First) Self Spouse

Responsible Party’s Birthday

Responsible Party SSN#

_____/_____/_____ Parent Responsible Party Address (if different from above) City State Zip Home Phone

Work Phone

Email Address

Cell Phone

Emergency Contact


Contact Phone

Primary Insurance Information Type of Insurance Primary Insurance Self Pay PPO HMO Medicare Policy # Group # Effective Date

Subscriber Name (Last, First)

Subscriber Birth Date _____/_____/_____ Secondary Insurance Information

Subscriber Social Security #

Type of Insurance




Medicare Policy # Group # Effective Date

Secondary Insurance

Subscriber Name (Last, First)

Subscriber Birth Date _____/_____/_____ Credit Card Information

Subscriber Social Security #

MasterCard Name On Card


American Express

Discover Credit Card Number Expiration Date

AUTHORIZATION AND CARE/RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS CONSENT TO TREAT The term “healthcare provider(s)” in this document means Mark L. Thornton, MD, FACP/Execudoc, Inc. its agent’s employees, members of the medical staff, their agents and employees, and other health care practitioners who provide care to patients. I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plan for care including future treatment. I understand that this information serves as: 1. 2. 3. 4. Basis for planning my treatment and care Information used to file my claim with the insurance company (procedure and diagnosis) Means by which a third-party payer can verify that billed services were actually provided A tool for routine health care operations including assessing quality and reviewing competency of your staff and/ or other health care providers.

I understand that I have been provided with the Notice of Information Practices that provides more complete information of uses and disclosures. I understand that I have the right to review the notice before signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy or post any revised notice to the address I have provided. I understand that I have the right to restrict how my health information may be used or disclosed to carry out payment, treatment, or health care operations and that the organization is not required to agree to the restrictions requested. I understand that I have the right to revoke this consent in writing, e3xcept to the extent that the organization has already taken action on my behalf. Permission is hereby granted to all health care providers involved in my care to administer such examination, treatment, testing, and procedures as are deemed necessary in the course of my care. RELEASE OF INFORMATION The health care provider involved in my care may release information about me necessary to substantiate my insurance claims. FINANCIAL RESPONSIBILITY/ASSIGNMENT OF BENEFITS For those health care providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to directly to that provider any benefits of any policies of insurance to those health care providers who have rendered services to me and who accept such assignment. I agree to pay all charges that are not paid in full by assigned insurance. If such amounts due to the health care providers are not paid after reasonable notice, that account shall be deemed delinquent and a service charge shall be added to the amount due. In the event that I default on payment of account, I agree to be responsible for collection fees and interest due on amounts in default, including court costs and reasonable attorney’s fees. If the debt is assigned to a third party for collection, I agree to be responsible for collection fees and interest due on amounts in default. MEDICARE LIFETIME BENEFICIARY CLAIM AUTHORIZATION AND RELEASE OF INFORMATION I request that payment of authorized medical benefits be made either to me or on my behalf to Mark Thornton, M.D., P.A./Execudoc, Inc. for any services furnished me by the physician/supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine benefits or the benefits payable for related services. I understand my signature requests that payment be made and I authorize release of medical information necessary to pay the claim. If other health insurance is indicated on item 9 of the HCFA-1500 claim form or elsewhere on the approved claim form or electronically submitted claim, my signature authorizes release of information to the insurers or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and deductible are based upon the charge determination of the Medicare carrier.

Signature and Date

Mark L. Thornton, MD, FACP/Execudoc, Inc.
Authorization for the Release of Medical Records
Patient Name: Last, First Date of Birth

Social Security Number

Telephone Home: ( ) Work: ( )

I Hereby Authorize: Facility or Doctor Address Phone and Fax To Release to the Following Person:

Mark L. Thornton, MD, FACP/ Execudoc, Inc. 7720 Jones Maltsberger, Suite 110 San Antonio, Texas 78216 Telephone (210) 822-2004 Fax (210) 822-2215
Reports to be released (please indicate) Complete Medical Record History and Physical Test Results Lab Results Referral Letters Progress Notes Conversations by Telephone HIV Test Results Other __________________ Insurance Personal Reasons

This disclosure is being made for the following purpose(s): Continuing Care/Referral Transfer of Care Attorney/Court Case Workers Compensation Other: _____________________________

I understand and acknowledge that this authorization extends to all or part of the records designated above, which may include treatment for physical and mental illness, and/or alcohol/drug abuse. I expressly consent of the release of information as designated above. This consent is valid for 180 days, unless revoked by me in writing before release of the above-designated information.

Patient Signature and Date

Mark L. Thornton, MD, FACP/Execudoc, Inc.
Notification of Protected Health Information
Use and Disclosure of Your Protected Health Information (PHI) Your protected health information will be used by Mark L. Thornton, MD, FACP/Execudoc, Inc. or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your protected health information. Mark L. Thornton, MD, FACP/Execudoc, Inc. may or may not agree to restrict the use or disclosure of your protected health information. If Mark L. Thornton, MD, FACP/Execudoc, Inc. agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices Mark L. Thornton, MD, FACP/Execudoc, Inc. reserves the right to modify the privacy practices outlined in the notice.

Signature I have reviewed this consent form and give my permission to Mark L. Thornton, MD, FACP/Execudoc, Inc. to use and disclosure my health information in accordance with it.

Patient Signature


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