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KEVIN TEAL M.D., P.C. Patient Contract with Doctor By signing below the patient or their parent/legal guardian agree to these conditions of being a patient of Kevin R. Teal, M. D. and understand their responsibility as well as the responsibility of the office and doctor. Contact This office will contact you by telephone regarding appointments, lab results or other information regarding your care. Please let the Doctor know if you do not want a detailed message left. Cancellation of appointments In the event that you need to cancel or reschedule an appointment, please call within 48 hours of your appointment day. Failure to do so will result in a $25.00 fee. This will apply to NO SHOW as well. Financial Co-payment is due at the time services are rendered. In some hospital and surgery cases, there is a deductible or a coinsurance amount due to the physician. This amount will be due before surgery and if it is not paid the surgery will be postponed. Please understand that the financial responsibility to the doctor exists with the patient and not the insurance company, therefore if no payment has been received from the insurance company within 90 days the payment will be expected of the patient. Unpaid Claim Payment Any unpaid claim payment due to deductible, co-insurance, co-pay will be sent to patient in the form of a statement. After 3 statements, a collection notice may be sent out. Failure to respond to requests for payment may result in the account being sent to our attorney’s office for pursuit of legal action. Insufficient Funds There will be a $35 fee for each returned check. Medical Records There will be a $1 fee for the first page and .50 cents per page thereafter. Please allow 10 business days for completion of each medical records request. Pain Management Patients will receive pain medications as deemed appropriate by the physician. Patients who get narcotic prescriptions from other physicians will not get narcotic prescriptions from this practice. If a patient is found to be getting multiple prescriptions from this physician and other physicians, a hold will be placed on receiving further prescriptions from this practice. Patients with patterns of medication use that exceeds recommended doses will not receive further prescriptions without talking with the physician. Patients who appear to repeatedly over use narcotics may be discharged from care. Urine drug tests will be done randomly for patients receiving narcotics. Medication refills All medication refill requests must be faxed from the pharmacy and will be reviewed by the physician for any narcotics. Refills approved or denied will be sent by fax within 72 hours during the week. No refills will be done after 5:30 pm on Friday. Treatment I hereby consent to the treatment by the deemed appropriate personnel of the office of KEVIN TEAL M.D., P.C. This includes taking a medical history and vital signs. I consent to Kevin R. Teal, M.D. to communicate with other physicians participating in my care. ______________________________________________ Signature of Patient, Legal guardian Parent of Minor

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______________________________________________ Printed Name of Patient

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