- New patient intake sheet.
- New patient intake sheet for Medicare patients.
- Medical record request/form completion request.
We respect patient confidentiality and are required by the State of Rhode Island and federal law to maintain the privacy of your protected health information. We must follow the privacy practices described in our Privacy Notice, although we reserve the right to change our privacy practices and the terms of this Notice at any time. Should our privacy notice change, we will post the change below and give you a copy at your next visit to our practice. You can also get a copy of this policy by calling our office at (401) 729-2800.
Office and financial policies
Thank you for choosing Affinity Orthopedics and Sports Medicine (AOSM) as your medical provider. Please read the information below before coming in for treatment.
On the day of your visit, please do the following:
- If you are a new patient, fill out and bring the completed New Patient Intake Form.
- If you cannot download the form, please arrive at least 15 minutes before your scheduled appointment time so you can fill out the necessary paperwork.
- Bring your insurance identification card so we can copy it for accurate insurance information.
- Bring your driver’s license or a photo ID so we can copy it for our files.
- If applicable, bring any referral from your primary care physician or authorization for services.
- Bring your co-payment.
- Bring copies of any previous x-rays that relate to your injury.
If you cannot keep your scheduled appointment, please call our office at least 24 hours before the appointment at (401) 729-2800.
Bring your insurance card to your appointment. For insurance plans we contract with, your carrier requires that all co-payments be paid before we provide service. We cannot waive this because it is your insurance carrier’s requirement. You are responsible for any co-insurances, deductibles or non-covered services as required by your insurance plan. While we make every effort to determine your benefits, a quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of your insurance plan at the time of service.
If you do not have health insurance or participate in a plan that we do not have a contract with, we can still schedule an appointment for you at our practice. You must pay for the services when you come in. Fees will be discounted when paid at time of service. If you cannot pay your balance in full, you need to make arrangements with our billing analyst before your appointment by calling (401) 729-2836.
HMO (health maintenance organization) or POS (point of service) plans
If we participate in your HMO or POS insurance plan, your insurance carrier requires that you obtain a referral from your primary care physician (PCP) before we can see you. Bring that referral with you to your visit. If you do not have a referral or proper authorization, you will have to reschedule your appointment or sign a “self-referral” authorization form which means that the visit will be your financial responsibility. Payment will be expected at the time of service.
Credit card policy
AOSM requires a valid credit card or direct bank debit account information before any surgery. We will apply a deposit based on any balances that your health insurance carrier has not paid for the procedure (deductibles, co-insurances, co-pays and/or non-covered services). Your credit card/bank account will be charged 24 to 48 hours before your surgical date. If your insurance carrier’s benefits and the amount of the deposit collected exceed the amount owed, we will refund the difference to you.
Fracture care is billed as a packaged service which includes the following:
- The first cast or splint application.
- Ten to 90 days (depending on the insurance carrier) of post-operative follow up care from the date of the fracture.
We will give you a copy of your x-rays upon request. You must to sign a letter of release (link) when you pick them up. Please give us 48 hours from the time of your request. If you have any questions or concerns, please call our office at (401) 729-2800.
Medical records requests
If you need AOSM to send your medical records to another office, please submit a completed Authorization to Release Health Information form. Medical records include and are not limited to office notes, surgical reports, and copies of x-rays taken at our facility. We cannot release outside records under HIPAA guidelines. You must get these records from the facility that generated them. Paper copies will be provided within 30 days of receipt of the written request. Our copy fees are:
Pages 1 to 50 $0.75 per page.
Pages 51 and higher $0.50 per page.
Retrieval fee, if needed within 48 hours $20 per chart .
Special reports/corm completion
If you need special reports for attorneys, third-party insurance forms, etc., you must send us a request in writing, outlining all pertinent information that needs to be completed or addressed in the report. We will determine the appropriate fee for service based on the quantity of information requested and the physician time that is required. We require payment before we give you the report. Third-party insurance forms will be completed within seven to 14 days of payment. Special reports will be completed within 21 to 30 days after payment.