CHILD PATIENT REGISTRATION FORM

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Ethnicity *
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During your pregnancy with this child
Hospital Birth? *
Home Birth? *
Labor and Delivery *
Newborn's Health *
Development (normal range in paranthesis)

OFFICE POLICIES

New Patient Visits: First visits can take up to 1½ hours. Depending on the patient’s needs, the emphasis will either be on homeopathy or osteopathy together with appropriate life-style recommendations. Please read the How To Report Symptoms page or the printed information which was sent to you by mail. Bring copies of recent laboratory work and other relevant medical reports as well as a list of all medications and supplements. If you are not using the online patient registration feature, please allow some extra time before your first visit to complete a patient registration form. The fees for a new patient visit are in the $350 -$400 range. Initial visits for infants and children generally take less time and the fee is adjusted accordingly. Three business days notice is required to cancel a new patient visit. Fees for return visits vary based on the number and kind of procedures performed, generally in the $195- $280 range.  Please call the office for details.

Dr. Masiello’s practice is office-based only, so patients are urged to maintain contact with conventional physicians for emergencies requiring hospitalizations, specialty consultation, surgery, diagnostic testing, gynecological services and routine cancer screening. He practices an integration of classical homeopathy and traditional osteopathy. Although homeopathy has been around for over 200 years, it is now considered to be alternative or non-conventional. Voice mail messages can be left 24 hours a day and he is available to established patients with urgent medical problems by cell phone.

Health Insurance: Dr. Masiello is enrolled in a few private insurance networks.  Please call the office for information. Dr. Masielo is a Non-Par Medicare provider.  The practice is currently closed to patients on disability.

Billing: Your treatment usually includes a medical office visit and an osteopathic treatment. As a courtesy, your claim will be submitted electronically on your behalf.  If you do not have insurance, you will be given a receipt for tax purposes without insurance codes.

Payment: Charges for all components of your treatment are due at the time of your visit. Cash, personal checks and credit cards (Master Card, Visa) are accepted.  In network patients are responsible for charges when their deductible has not been met and for any applicable co-payments. . There is no charge for a single dose of a remedy (pellets) dispensed at the time of the office visit. There is a fee for tinctures, liquid remedies and remedy tablets.  A separate receipt will be issued for medication charges.

Discount:  There is a 15% discount for patients without health insurance or who are part of a network and will not get reimbursed for seeing a non-network physician. Discounted patients will receive a receipt  without insurance codes for tax purposes.

Receipts:   Receipts for tax purposes are provided for patients without insurance. As a courtesy, all claims for patients with insurance will be submitted electronically. 

Cancelled or Missed Appointments:  As a courtesy, electronic reminders are sent out 5 days before your appointment. Please select among the following options: confirm, cancel or reschedule. Appointment changes must be made 5 days before your appointment time to avoid a missed office visit fee.

Lateness: The methods Dr. Masiello uses are labor-intensive and require the allotted time to complete so please maximize your experience by being on time. If you are late for your appointment and if the next patient has arrived early, the next patient may be seen during your appointment time in an effort to preserve the rest of the day’s schedule and not shortchange any one patient.

Phone Consultations: Phone consultations are only for established patients who need homeopathic prescribing on weekends or after office hours. Phone consultations are not meant to replace an office visit. There is a $125 fee for phone consultations. Payment by credit card is required for the consultation. If the remedy prescribed during the phone consultation has not worked, you will be asked to come to the office for treatment the next day the office is open.  The $125.00 fee will be deducted from the office visit fee so you will not pay twice for the same episode. Remedy kits for home prescribing are available via a link from this website.

A Word About Fees:  Dr. Masiello is dedicated to making holistic medicine available at a reasonable cost. He  has set his prices at or below the fees listed in the Fair Health database. Return visits are based on the patient’s individual response to treatment and not on a fixed schedule. Homeopathy and osteopathy are used together to make the process time efficient and cost effective. The interval between visits increases as the patient responds to homeopathic remedies in the high potency range.


I understand that I am financially responsible for all charges, including any balance remaining after payment of health insurance benefits. I give my permission to release information needed for processing any health insurance claims.

 

I have read and agree to the above office policies *
Holistic Family Medicine, LLC
141 East 55th Street
New York, NY 10022
212-688-4818