These forms are from your kidney specialist at Nephrology Associates. We are the Nephrology group managing your care at the Davita dialysis unit.

These forms require your signature so we can bill your continued care to your insurance company.

Patient Registration: Gives us your demographic and insurance information and allows you to give permission to people you chose, other than yourself, that you would like us to speak with about your account, appointments and/or billing.

Financial Policies Insurance/Medical Records Auth: Gives us authorization to bill care to your health insurance and acknowledge that you have received a copy of our Privacy Practices for your records.

Thank you so much,

Billing Specialists Department Ph: 816-474-0458

Patient Registration

Patient Name

Preferred Name

Social Security No.

DOB

Gender
Male Female

Address

City

State

Zip

Email

Are you disabled?
Yes No

Cell Phone

Leave Message?
Yes No

Home Phone

Leave Message?
Yes No

Employer

Occupation

Pharmacy

Phone

Preferred Lab

Preferred Hospital

Primary Care Physician

Referring Physician

Upload Photo ID
To select multiple files, hold down the CTRL or SHIFT key while selecting.

If other family members are seen in this office, please list:

Emergency Contacts / Release of Medical, Billing and Appointment Information

I authorize Nephrology Associates M.D., PA to discuss my medical, billing and appointment information with the following individuals:

Spouse Name

Phone

DO NOT discuss billing

Contact Name

Phone

DO NOT discuss billing

Relationship to Patient

Add another?

Financial Policies
Insurance / Medical
Records Authorization

By signing and/or receiving medical services from Nephrology Associates, you agree to the following:

I request payment of authorized Medicare, Medigap, or other insurance benefits to Nephrology Associates, M.D., P.A. for any services provided to me by those physicians and or nurse practitioners; I understand that I will be responsible for any coinsurance, deductible amounts, and any non-covered services.

I hereby authorize Nephrology Associates, M.D., P.A. to release medical or other necessary information required by my private insurance carrier, Medicare, Medigap and its agents to determine benefits for services provided.

This authorization will also permit Nephrology Associates, M.D., P.A. to provide requested information or excerpts from the patients record to any physician, hospital, laboratory, radiological facility, or other health care provider from which the patient has been referred or being referred to support continuity of care.

I understand that I am required to give a 24-hour notice if I wish to cancel my appointment so that my time can be given to another patient. Nephrology Associates, M.D., P.A. reserves the right to charge a $50.00 “no show” fee if I fail to provide this notice.

Additionally, I understand that I have a contract with my insurance company that governs co-payments for office visits. Co-payments must be paid prior to being seen by the physician/nurse practitioner. If co-payment is not received, I may be required to re-schedule my appointment.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization is considered as valid as the original. I certify that I have read and understand the “Financial Policies” and agree to all terms and conditions stated above.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.

Date

Patient Name

Insurance Information

Do you have healthcare insurance?
Yes No

“Self-Pay” Patient Payment Policy and Good Faith Estimate
Definition: “Self-Pay” is any individual that either does not have any insurance coverage or has insurance coverage where our Physicians or Nurse Practitioner are considered as NON-PARTICIPATING or chooses not to utilize their benefits.

Below you will find the Monthly Dialysis charge amount for management by your physician of dialysis related services and their cost to you. The estimated costs are valid for 12 months from the date of this Good Faith Estimate (GFE).

Monthly ESRD Management service codes 90960, 90961, or 90962. A statement for these services will be mailed to you. Once received, payment in full will be expected. Charge amount per month: $442.50

I agree to the Self-Pay Policy as stated above.
Patient Name

DOB

Date

*Signature not required for policy to be enforced

Disclaimer

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" for self-pay care. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

If you are billed $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Do you have Medicare?
Yes No

Is this medical condition due to an accident of any kind?
Yes No

Is the patient covered by an employer’s health insurance plan through their own employment or that of a family member that is not retiree coverage?
Yes No

Notice of Privacy Practices

Click here to view and print our Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have received Nephrology Associates, M.D., P.A. Notice of Privacy Practices, and a personal copy was made available for me.

Date

Patient Name

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Patient Registration

Financial Policies Insurance / Medical Records Authorization

Insurance Information

Notice of Privacy Practices

Financial Policies
Insurance / Medical
Records Authorization