New Patient Form – Step 2

Please take time to read the following material.

You do not need to print this page since copies will be given to you at the time of your appointment.

A Message to Our Patients About Arbitration
The attached contract is an arbitration agreement. Please review this document now. You will be asked to sign a copy of this form provided to you on your first office visit. By signing this agreement you are agreeing that any dispute arising out of medical services you received is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both patients and physicians. Arbitration agreements between health care providers and their patients have long been recognized and approved by California courts.

By signing this agreement you are changing the place where your claim will be presented. You may still call witnesses and present evidence. Each party selects an arbitrator (party arbitrators) who then selects a third neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both the patients and physicians. Further, both parties are spared some of the rigors of trial and the publicity that may accompany judicial proceedings. Our goal, of course, is to provide medical care in such a way as to avoid any dispute. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.

Insurance and Financial Information
Gynecologic Oncology Associates is committed to providing you with the best possible medical care and assistance with payment issues. In order to achieve these goals, we need your help and your understanding of our insurance and financial policy.

If you have insurance coverage, we are anxious to help you receive your maximum allowable benefits. In order to do this, we will need complete insurance information from you. Please bring your insurance card(s) with you to your first appointment. We will keep this information on file. If your insurance changes, please notify us immediately.

If you are a member of a PPO, HMO, Medicare, or Champus, we will follow the plan’s guidelines for billing and collections, and you will only be required to pay any deductibles and copayments which you owe, or for any services which you agree to, but which are not covered by your insurance. Please be prepared to pay your copayment and deductibles at the time of your visit.

If you are Medi-Cal/Medi-Cal HMO patient, please be prepared to pay any Share of Cost that is your responsibility at the time of your visit.

If you do not have insurance coverage, you are expected to pay for services, in full, at the time of each visit; and you will be expected to pay in advance for any surgeries are procedures that we schedule for you.

If you are a member of an HMO, or any other insurance plan that requires prior authorization for services, please be sure to obtain that authorization before your appointment. If we do not have authorization on file for you, we will not be able to see you. Unfortunately, many HMO’s will not pay for medical services if they have not been preauthorized. Also, please notify the nurse if your plan requires you to use a specific laboratory or radiology facility.

Please keep in mind that as health care providers, our relationship is with you, not your insurance company, therefore, you may be responsible for charges that your insurance company does not pay in full. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, please contact us immediately for assistance in the management of your account. for your convenience, we accept cash, checks, Mastercard, Visa, Discover, and American Express Cards.

If you have any questions about your account, please contact our billing office at (800)416-0888.

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