Thank you for coming to Integrative Health Care of Winona, PA. We have certain policies which have been developed to help us prepare for your appointment, and to ensure that the time and effort which we have made on your behalf is understood.
Scent Free Policy: Many of our patients are chemically sensitive to scents, perfumes lotions, and hair gel. We ask you that you refrain from wearing scented products on the day of your visit. You may be asked to reschedule if you have a scent on at time of visit.
Cancellations: All cancellations must be made at least 24 hours prior to appointment time. We reserve the right to charge for missed or cancelled appointments if cancelled within 24 hours.
Phone consultations: Telephone calls with the physician will be billed as telephone consultations. Charges for these consultations will be added to your account, and will be charged to the credit card you authorize us to bill. Phone consultations include conversations that report on tests and/or laboratory results, clarify or alter previous instructions, integrate new information from other health professionals into the medical plan, or adjust therapy. You may inquire into charges for brief, moderate, or extended phone consultation. Answers provided through clinic staff are not charged unless they are extensive. E-mail will be billed as phone consultations.
Type of Care Provided: Dr. Vrchota specializes in Holistic Medicine, and cannot be your primary care provider. This means you must have another physician to provide you with acute or emergency care, prescribe your chronic medication, and help you if you need surgery, etc. Dr. Vrchota's services are complementary to your primary care. She will be happy to discuss your care with your primary care provider if you request and authorize her to do so.
Payment: All balances are due and payable at time of service. We will provide you with a receipt with diagnostic codes that you can submit to any insurance except Medicare/Medicaid/Champus (see notification to Medicare Medicaid Programs). Please go to your insurance carrier's website and print off their HCFA billing form, as each insurance varies slightly. We do not submit claims for you. Your insurance company may or may not cover any or all of the services which you received at Integrative Health Care of Winona, PA.
I have read, understood, and agree to abide by the above policies. Any questions I had about these matters were answered to my satisfaction by office personnel.
Patient or Responsible Party Date Witness