Patient Information Forms

A Statement of Understanding

 I agree that the determinations of professional services to be rendered by my doctor and the fees to compensate him for these services are matters concerning my doctor and me.  I understand that I have the primary duty and obligation to pay my doctor for services, notwithstanding any contract that I may have with any third party (be it an insurance company, employer, union, government, or the like).  Neither my doctor nor I will permit any party to determine what medical services I need or what fees the doctor should receive in return for these services.  Any agreement that either of us may have with any third party shall not affect our doctor-patient relationship and the decisions relating to medical care and fees.  Neither my doctor nor I, as his patient, are in any way bound by any contract the other may have with any third party.

 I also understand that payment is due on the day that service is rendered.

WE DO NOT PARTICIPATE WITH ANY INSURANCE PROVIDERS AND AS SUCH, THE ALTERNATIVE & TRADITIONAL MEDICAL CENTER DOES NOT ACCEPT MEDICARE PAYMENTS. WE WILL NOT FILE ANY MEDICARE CLAIMS OR PROVIDE YOU WITH ANY CPT OR DIAGNOSTIC CODES FOR YOU TO FILE ON YOUR OWN WITH ANY INSURANCE CARRIER.

 Robert Gilbard, MD is no longer a MEDICARE PROVIDER.  The effective date begins on July 1, 2009 and goes through June 30, 2011 (a period of 2 years with an option to opt-out for another 2 year period).

**ANY MISSED APPOINTMENT WITHOUT AT LEAST A FULL 24 HOUR NOTICE YOU WILL BE CHARGED.  PLEASE, ALSO UNDERSTAND, IF YOU ARE MORE THAN 30 MINUTES LATE YOU MAY HAVE AN EXTENDED WAIT TO BE SEEN OR WE RESERVE THE RIGHT TO RE-SCHEDULE YOU FOR A LATER DATE.