International Patients

Agreement of Financial Responsibility

Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

  • Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider and are the designated Primary Care Provider (PCP), if applicable.
  • It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
  • We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
  • If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.
  • If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.
  • Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.

I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility.

I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.

______________________________

Signature of Patient /Responsible Party

_______________________________

Date Name of Patient/Responsible Party

PATIENT CONSENT FOR TREATMENT
  1. CONSENT FOR TREATMENT.
  • I voluntarily consent to inpatient and/or outpatient care and treatment performed by my physician and all other health care providers at University of Colorado School of Medicine health care delivery sites.
  • I also consent to routine services, diagnostic procedures, medical treatment, other health care services deemed necessary by the health care providers treating me.
  • I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may cause injury or even death.
  • I understand that I have a right to consent or to refuse to consent to any proposed surgery, procedure or treatment, and to discuss it with my health care provider.
  • I also understand that in the course of my medical treatment I may have one or more photographs of my skin or wound(s) taken, to use in monitoring my treatment and guiding healthcare provider interventions.
  • I understand that individuals who want to learn about the roles of healthcare providers may observe the treatment I receive and I consent to this but I have the right at any time to object to letting such an individual observe and my objection will be honored.
  • If this Patient Registration and Consent for Treatment is signed as part of an Emergency Department or other outpatient visit, it will continue for any related inpatient admission.

 

  1. AUTHORIZATION, FOR RELEASE OF INFORMATION.
  • I authorize University of Colorado School of Medicine and its health care delivery sites to utilize confidential medical/Surgical or other information contained in my medical record as necessary for claims payment, medical management, or quality of care review purposes.
  • I further authorize the release and discharge of such confidential, information to my insurance company or other health coverage plan, including government payers, as necessary for claims payment, medical management and quality review activities conducted by such company or plan, or its designees.
  • This authorization includes the release of an Acquired Immunodeficiency Syndrome (AIDS) diagnosis or a positive Human Immunodeficiency Virus (HIV) antibody test result, alcohol and/or drug abuse information, genetic testing, congenital disorders, and mental health information.
  • I understand this authorization for release of information can be revoked by me in writing at any time, but only with respect to the proposed treatment and not with respect to care and treatment that has already been rendered to me.

 

  1. WAIVER OF RESPONSIBILITY FOR PERSONAL VALUABLES.

I understand that the University of Colorado School of Medicine or any of its health care delivery sites do not assume any responsibility for the loss or damage to my personal property.

  1. PAYMENT AGREEMENT AND ASSIGNMENT.
  • Except as prohibited by any agreement between my insurance company and The University of Colorado School of Medicine,University Physicians, Inc. (Faculty Practice Plan) or by state or federal law, I agree to be responsible for my co-payments, deductibles or other charges for medical services not covered or paid by insurance or other third party payers.
  • I authorize The University of Colorado School of Medicine and University Physicians, Inc. to file any claims for payment of any portion of the patient bills and assign all rights and benefits to The University of Colorado School of Medicine and University Physicians, Inc. as appropriate.
  • I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses and interest in the event The University of Colorado School of Medicine and University Physicians, Inc. take action to collect same because of my failure to pay in full all incurred charges.

 

I have read this form, and by signing this form I understand and agree to what it says. The consent for treatment shall be effective for (1) year.

_______________________________ __________

Patient Signature Date Or parent/guardian/other authorized person if Patient is a minor, mentally incompetent,

_______________________________ _______________________________

 Witness to signature

 

PATIENT REGISTRATION FORM

 

Today’s Date: [Date]

 

PATIENT INFORMATION

Patient’s last name: [Last Name]

First: [First Name]

Middle: [Initial]

[Choose an item]

Marital status: [Choose an item]

 

Is this your legal name?

If not, what is your legal name?

Former name:

Birth date:

Age:

Sex:
 

[Legal Name]

[Former Name]

[Birthday]

[Age]

  

Address:

 

Social Security no.:

Home phone no.:

Cell phone no.:

[SS#]

[Phone]

[Phone]

Occupation:

Employer:

Employer phone no.:

[Occupation]

[Employer]

[Phone]

 

Chose clinic because/referred to clinic by (Please choose one option):

  

[Doctor’s name]

 

  

[Choose an item]

Other family members seen here: [Other patients]

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

[Responsible party]

[Birthday]

[Address]

[Phone]

Is this person a patient here?

  

Is this patient covered by insurance?

  

Occupation:

Employer:

Employer address:

Employer phone no.:

[Occupation]

[Employer]

[Address]

[Phone]

Please indicate primary insurance:

Subscriber’s name:

Subscriber’s Insurance Number

Birth date:

Group no.:

Policy no.:

Co-payment:

[Name]

 

[Birthday]

[Group #]

[Policy #]

$[Co-pay]

Patient’s relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber]

Name of secondary insurance (if applicable):

Subscriber’s name:

Group no.:

Policy no.:

[Secondary Insurance]

[Name]

[Group #]

[Policy #]

Patient’s relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber]

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

[Friend or relative name]

[Relationship]

[Phone]

[Phone]

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims.

 

 

 

 

 

 

Patient/Guardian signature

 

Date

 

 

INTERNATIONAL PATIENTS INFORMATION

AMP assists individuals from other countries who are seeking specialized care outside their country of origin. Our staff coordinates all aspects of your visit to our clinic and collaborating hospitals and is committed to making you and your family as comfortable as possible during your stay. Each patient receives care in an environment that respects diverse cultural traditions and backgrounds. Our goal is to provide you with a level of customer service that matches the world-class medical treatment you will receive.

Additional Services

In addition to coordinating care with world-class physicians and state-of-the-art medical technology, our patient liaisons can assist you with the following:

  • Coordinating interpreters and translation services
  • Arranging international communications with physicians and family
  • Providing information on short- and long-term accommodations
  • Identifying resources for spiritual or religious guidance

Please note that International Services does not provide medical advice over the phone or by email.

To get started on arranging your visit to AMP, please follow the steps below:

Step 1: Registration

You may register online or via email, mail or fax:

 

Step 2: Medical Records Submission

Upon receiving your enquiry one you will be asked to complete a Medical Questionnaire which provides us with detailed information to your personal health situation. Our nurse coordinator will assist you and guide you through the process. You may be required to send us via email a photograph of the area that needs treatment. Specific information for your treatment will be send to you.

You must have all of your medical records professionally translated into English and submit them to our office before we can schedule your appointment. We cannot accept records that have not been professionally translated. Records may include physician notes, radiology and pathology reports, lab results and radiological images.

You may send us your medical records via email, fax or mail. Our contact information is listed to the right, under “How to Reach Us.”

Step 3: Medical Records Review

After we receive your medical records, our medical team will review them to determine if AMP offers treatments that may benefit you. After the surgeon reviews your request, medical history and photographs he will contact you via email or the phone in order to ask you specific questions and answer possible questions you may have.

Step 4: Financial Clearance

Once you are accepted for care at AMP, we will provide you with an estimate of financial charges for the care. Prior to receiving care, you will need to pay a percentage of the charges in full or provide verification of authorization from an insurance plan accepted by AMP.

Step 5: Appointment Scheduling

Once you have made your decision to have your surgery then we will finalise your booking in the hospital and start making all the necessary arrangements for your operation. We can assist and arrange all the necessary travel packages (accommodation, tickets, etc).

A detailed itinerary will be prepared and the total cost will be finalised. At this point a confirmation letter will be sent to you with all details regarding your operation, along with a Consent Form that mentions that you understand all the details pertaining to the operation and the travel arrangements and that you accept the cost. You need to sign the forms and return them to us.

Step 6: Payment

Full payment should be wired to an account we will provide by the time you arrive in Greece or Cyprus for your initial live consultation. All payments to the hospitals / clinics / doctors and hotels are made by us so you would only need to take with you spending money.

Once your payment has been received your flights are confirmed and your travel documentation is sent to you (which you need to take with you on your trip).

 Step 7: Arrival – Consultation with your Surgeon – Pre-op Tests

Upon arrival at the airport you will be met by a representative from our practice. A driver will then take you directly to the clinic and then to your hotel.

When you arrive at the clinic you will meet with our registered nurse and the surgeon. Your consultant will explain all about the procedure you are having done and you have the opportunity to discuss and ask any questions related to the operation directly with your surgeon. Then our registered nurse will help you with your pre-op tests and will guide you to the hospital.

 Step 8: The Surgery

On the day of the surgery you will check to the admission office of the hospital to register. Our nurse coordinator will be with you. Our anesthesiologist will also meet you and will explain what to expect before, during and after the surgery. You will also meet the nursing staff who will be responsible for looking after you during the hospital stay.

 Step 9: After the Surgery

Following the completion of the surgery you will stay in the hospital for a few hours to a few days depending on the surgery. After you are discharged from the hospital, you will then be taken to your hotel where you will stay for your post-operative period until you return back to your country. During the recovery at your hotel you will be visited by our nurse daily. You will be given detailed instructions and contact details for the clinic, the doctor, the hospital. Prior to departure to your country you will visit the clinic so the surgeon can examine you. Further detailed instructions will be given to you.

 Step 10 Travelling back

You will be accompanied to the airport by our driver and nurse. If it is required, wheelchair assistance will be arranged for your journey home.

You will be given 7 days worth of medication and detailed instructions along with a “Medical Note” detailing everything about your treatment that you can give to your GP so that your medical records are kept fully up to date.

Step 11: Recovery at home

After returning to your country, if you have any questions relating to your surgery procedure then please contact us immediately and we will arrange for a collaborating surgeon or doctor at your area to examine you.

Once you are back home our registered nurse and your surgeon will contact you to ensure that your recovery is uneventful.

At six months you may be asked to send us photographs of the areas treated. You can always visit us back in Greece or Cyprus at any time for a check-up of the results.