Patient Information & Forms

NEW PATIENTS
If you are searching for a primary care physician and in need of the best possible healthcare, you have come to the right place.Richichi Family Health is currently accepting new patients. Please stop by our office or complete the following registration packet and fax it to (239) 593-0067. You can also email the registration packet to info@richichihealth.com.

NEW PATIENT FORMS
Notice of Privacy Practices (Please read prior to signing the consent form)
New Patient Registration Packet
Medical Records Release

ESTABLISHED PATIENT FORMS
Pre-Appointment Questionnaire
Change/Update Patient Information
Advance Beneficiary Notice of Non coverage (ABN)

INSURANCE PLANS
The following is a summary of insurance plans we participate with and is subject to change without notice. If your insurance is not listed
here, please contact your insurance company to verify if Richichi Family Health providers are participating with your insurance company:

** You will be personally responsible for your charges until we receive a copy of your insurance card.

If we do not participate with your insurance company, we will courtesy file and collect the deductible/co-payments at the time of service. If
we have not heard from your insurance company after 60 days the bill is due and payment by you is expected immediately.

Past due accounts are subject to attorney’s fees, court costs, and other costs of collection. Please note, a surcharge may be applied for
missed appointments and for co-payments not paid on the date of service. Any patient whose account remains delinquent for 90 days or
more is subject to dismissal from the practice.

Please remember: Your insurance is a contract between you, your employer, and your insurance company. You are personally responsible
for any bill, or portion thereof, not paid by your insurance company.

Please click here to download the handout Understanding Your Insurance Coverage.

Please click here to download the handout Understanding Your Health Plan’s Rules.

PAYMENT POLICY
We are committed to providing you the best possible care. In order to better serve you by keeping our overhead costs low, Richichi Family Health, has adopted the following payment policy. Please read and familiarize yourself with this policy so that future misunderstandings regarding our billing and payment policy can be avoided. If you have any questions, please do not hesitate to speak with the Billing office.

Please click here to view our Payment Policy.
Please click here to download the handout Understanding Your Medical Bills.

PATIENT SATISFACTION SURVEY

Please click here to download our patient satisfaction survey.