Appointment Billing Information

•  OFFICE VISIT: This is a problem-based visit to discuss new or existing medical issues. The exam and questions will focus on the reasons for the visit. This may also include a follow-up on chronic problems {e.g., diabetes, cholesterol, blood pressure). During this visit, your healthcare provider may prescribe medications, order lab tests, perform in-office procedures, and/or make referrals to specialists. Telemedicine visits will be billed to insurance as a visit, with coding to indicate the manner of the visit. A co-pay will be charged at this visit, consistent with standard office visits.
•  ANNUAL PHYSICAL: This type of visit is preventive and is intended for patients who are asymptomatic and have no complaints but wish to receive a complete physician examination. It includes a thorough review of your general well-being, which may encompass recommendations regarding diet and exercise, ageappropriate immunizations, and screenings.
•  OFFICE VISIT AND PHYSICAL (BOTH): This refers to a scenario where a physical exam and an office visit occur during the same appointment. For example, if you present for a physical and also have an acute or chronic issue to address, it is considered a combination visit and must be billed differently than either a physical or an office visit alone.
•  HOW THIS COULD AFFECT ME: Many insurance companies recognize the office visit/physical combination; however, some may still require the patient to pay a co-pay or have additional costs applied to their annual deductible or coinsurance. Physicals are targeted as preventive care and are billed accordingly. Medication refills and/or other ailments, injuries, or illnesses addressed during the physical will be billed in addition to the physical itself. These charges may be passed on to the patient. Please check with your insurance company to confirm your coverage for all types of doctor visits. We understand this can be confusing, so if you have any questions or concerns after reviewing this material, please ask.

Financial and Patient Responsibilities

I understand that my insurance and subsequent charges will be billed by Dr. Mohammed S Ur Rehman, MD / Servicing Provider doing business as Primecare360. I agree to cooperate in the reimbursement process for the medical care and services provided. I understand that I am responsible for any amounts not covered by my insurance provider(s), including, but not limited to, any applicable co-payments, co-insurances, and deductibles.

If there are any questions regarding your bill or the billing process, please call +1 214-833-3100

Assignment of Benefits and Insurance Payments

I authorize Primecare360 to submit insurance claims and any other information necessary to bill my insurance provider(s) on my behalf for the products and services provided by Dr. Mohammed S Ur Rehman, MD / Servicing Providers and staff. I authorize the payment of medical benefits from my insurance provider(s) directly to Primecare360 for the products and services rendered. I agree to endorse and forward any payments made to me by my insurance provider(s) to Primecare360 for products and services billed under this agreement.

By signing this consent form, I agree to all the terms and conditions listed above. I certify that I have read this consent form carefully before signing and fully understand itsterms. A copy of this consent form will be provided upon request