Welcome to Star Family Medicine
Dr. Adam Khadbai /Dr. Brandee Pemberton
Kelly Kaldenbach PA-C/Debra Caldwell NP
929 Hilltop Dr Weatherford, TX 76086
Ph-817-341-7670 F: 817-341-7678
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Business hours are from 7:30am to 5:00pm Monday through Thursday, Friday 8:00am to 12:00pm.
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Bring a valid US government photo ID, insurance card(s) and a form of payment.
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Please complete ALL attached forms prior to your appointment.
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Please bring ALL prescribed medications, supplements, vitamins that you are currently taking to this appointment.
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If you have been seen by a doctor/emergency room please bring the name, address, phone, and fax for each so we may request your medical records.
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Please bring your immunization record with you. For patients under 18 years of age, failure to provide an immunization record may result in rescheduling of the appointment.
Star Family Medicine does not write prescriptions for the following medications:
Hydrocodone, Oxycodone, Oxycontin, Dilaudid, Methadone, Percocet, Fentanyl, Soma, Carisoprodol, Morphine
Xanax, any form of Benzo
If in the event you take any of these medications daily, please contact our office prior to your appointment.
Please note that we are a Pro Vaccine Clinic, if you choose to not Vaccinate your Children you may be asked to find another PCP.
By not vaccinating your children you are placing our staff, pediatric patients, and elderly patients at unnecessary risk
Welcome to Star Family Medicine, PLLC. We are committed to giving you the best care possible.
We would like to take this opportunity to inform you of our office policies.
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We will bill insurance claims as a courtesy to our patients provided, we have your current insurance information, if not; you will be responsible for payment at the time of service. It is your responsibility to notify our office if there is a change of name, insurance coverage, residence and/or phone number.
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We accept payment from insurance companies, but require that you pay your portion, including co-pays, deductibles, or coinsurance at the time of service. In accordance with our participation agreements with third-party payers, we cannot waive or discount co-payments. Payment is due upon receipt for any balance that is billed to you.
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We participate with many plans; but there are some that we are “Out of Network” with. We attempt to notify every patient prior to their appointment/time of scheduling; however, it is the responsibility of the patient to contact your insurance to verify “in network status”. You will be responsible for charges, deductibles that your insurance plan decides. Many “out of network” plans charge you “the patient” higher office visit rates. Our office cannot discount this rate, adjust off balance etc.
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Please be aware that some or all services you receive may not be covered or not considered medically necessary by Medicare or another insurer. You must pay for these services in full at the time of your visit and a signature is required from you prior to services being rendered.
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The office bills only for services performed by our providers. The laboratory companies are a separate entity and will bill you or your insurance company for labs that are performed. If you have any questions regarding your lab bill, please contact the laboratory or your insurance company.
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In the event your account is paid late, placed on a payment plan, or your account is placed in collection status, any additional fees incurred due to this, will be added to your outstanding balance. This includes but is not limited to late fees, collections agency fees, court fees, court costs, interest, and fines. If the account is sent to collections or if we receive a bankruptcy notification, we reserve the right to dismiss you as well as any family members from the practice.
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Please allow 72 business hours for all medication refill requests. For any controlled medications please contact the office at least 4 days prior to running out. We will not authorize “early” refills.
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It is your responsibility to notify the office at least 10 days prior to any appointment that may require a referral. Some insurance companies require 7 days to approve these requests. If you fail to notify our office, you may be responsible for charges from your specialist. We are unable to “back date” referrals. We will attempt to find at least one provider in your network. If we are unable to locate one or you choose not to use this provider, it will be your responsibility to contact your insurance and choose a provider in your network. Then contact our office and provide information.
Please Sign below so that we may confirm that you have read and understand our office policy regarding insurance and your responsibilities as a patient of Star Family Medicine.
Please bring your driver license and insurance cards to your appointment
Person to Contact in Case of Emergency:
We strongly feel all patients deserve the best medical care that we can provide. Everyone benefits when financial arrangements are agreed upon. We have prepared this material to acquaint you with our policy. Our professional services are rendered to you, not the insurance company. Payment for treatment is your responsibility.
FINANCIAL/INSURANCE AGREEMENTS:
Please initial:
_________ In the event I have no insurance coverage, I understand that I am responsible for payment of services rendered to me or my dependents at the time of service. I understand if I fail to pay amounts owed: the clinic has the right to secure an outside collection agency and/ or attorney to collect the unpaid debt and to report the unpaid debt to a credit- reporting agency. I further understand that I will be responsible for any additional charges or fees necessitated by securing the collection agency or attorney, including reasonable attorney’s fees. I hereby authorize the release of any information necessary to process insurance claims and request payment of benefits to be made for services rendered to my dependents or to me. I understand I am responsible at the time of service for paying any required co-payment and deductible.
Changing or re-coding claims once they have been submitted constitutes fraud and we do not do this under any circumstances.
I have read and understand the payment policy of this office and agree to abide by the said policy. I understand a $30.00 charge will be assessed on all returned checks.
Due to the Health Portability and Accountability Act (HIPAA) of 1996, the following information must be filled out by each patient annually.
Your rights are posted in the waiting rooms at each Star Family Medicine. Copies of the rights are also available at the receptionist desk if you would like to keep this information for your records.
I authorize Star Family Medicine to release any of my medical or insurance information necessary to process my medical claims and coordinate/manage my healthcare.
With whom may we discuss information about your care, treatment or diagnosis?
I acknowledge the HIPAA Patient Rights and Privacy forms. I have read and understand my rights.
ELECTRONIC MEDICAL RECORDS HISTORY
Star Family Medicine utilize an Electronic Medical Records (EMR) System in our office.
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We now have the ability to check your prescription eligibility and download your pharmacy history into our system.
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We also have the added ability to fax mail order prescriptions, review prescription benefits, and drug formulary all while you are in our office.
By signing below, you are granting Star Family Medicine permission to obtain this information on your behalf.
I, the patient/parent of a minor, give my consent to Star Family Medicine to obtain my pharmacy benefits.
Star Family Medicine
SUMMARY NOTICE OF PRIVACY PRACTICES
THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION.
Our pledge to protect your privacy:
Star Family Medicine is committed to protecting the privacy of your medical information. Your care and treatment
is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with
the providers involved in your care. We share your information only to the extent necessary to collect payment for
the services we provide, to conduct our business operations, and to comply with the laws that govern health care.
We will not use or disclose your information for any other purpose without your permission.
Participant Rights - You have the following rights regarding your medical information:
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to request to inspect and obtain a copy of your medical records, subject to certain limitations.
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to request to add an addendum to or correct your medical record.
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to request an accounting disclosure of your medical information.
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to request restrictions on certain uses or disclosures of your medical information;  to request that.
we communicate with you in a certain way or at a certain location;  and to receive a copy of the full
version of our Notice of Privacy Practices.
We may use and disclose medical information about you for the following purposes:
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to provide you with medical treatment and services.
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to bill and receive payment for the treatment and services you receive.
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for functions necessary to run Star Family Medicine and assure that our participants receive.
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quality care.
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to provide basic contact information (no medical information is provided) for our development.
office for purposes of fundraising for Star Family Medicine  to support our standing as a federally.
qualified health center;  and as required or permitted by law.
There are additional situations where we may disclose medical information about you without your
authorization, such as:
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for workers’ compensation or similar programs.
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for public health activities (e.g., reporting abuse or reactions to medications).
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to a health oversight agency, such as the Texas Department of Health Services.
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in response to a court or administrative order, subpoena, warrant or similar process.
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to law enforcement officials in certain limited circumstances.
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to a coroner, medical examiner or funeral director; and
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to organizations that handle organ, eye, or tissue procurement or transplantation.
Our Notice may be revised or updated from time to time. Please see our full Notice of Privacy Practices for a more
detailed description of our privacy practices, your rights regarding your medical information, and pertinent contact
information.
For further information about the full Notice of Privacy Practices, please contact: Star Family Medicine
Privacy Officer at (817)-341-7670. A complete version of this notice is available on our website at www.
Starfamilymedicine.com
Star Family Medicine
ACKNOWLEDGEMENT OF RECEIPT
OF SUMMARY NOTICE OF PRIVACY PRACTICES
Our Notice of Privacy Practices provides information about how we may use and disclose protected health.
information about you. The notice contains participant rights section describing your rights under the law. You
have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change
our Notice, you may obtain a revised copy by contacting our office at (817)341-7670
You have the right to request that we restrict how protected information about you is used or disclosed for
treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall.
honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment,
payment and health care operations. You have the right to revoke the Consent in writing, signed by you. However,
Such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Star
Family Medicine Health provides this form to comply with the Health Insurance Portability and Accountability Act
of 1996 (HIPPA).
The participant understands that:
• Protected health information may be disclosed or used for treatment, payment or health care
operations.
• Star Family Medicine has a Notice of Privacy Practices, and that the participant has the
opportunity to review this notice.
• Star Family Medicine reserves the right to change the Notice of Privacy Practices.
• The participant has the right to request restrictions on the use of their information, but Star Family
Medicine does not have to agree to those restrictions.
• The participant may revoke this Consent in writing at any time and full disclosure will then cease.
• Star Family Medicine may condition receipt of treatment upon the execution of this consent.
I have received a copy of the Summary Notice of Privacy Practices. I understand that I may also request a copy of
the practice’s complete Notice of Privacy Practices if I so desire.
Star Family Medicine
Authorization for Release and/or Disclosure of Health Information
​I authorize the disclosure of my personal health information to the persons/entities as described below. I understand this authorization is voluntary and made to confirm my directions. I understand that once the information is disclosed, it may be re-disclosed and no longer protected by federal privacy regulations. I hereby give permission to Star Family Medicine to disclose my personal health information in the manner described herein.
