Policies and Agreements
Please review and acknowledge the following policies. These help ensure we can provide you with the best possible care.
Minor Consent Form (Pediatric Patients)
REMINDER: ALL PEDIATRIC PATIENTS UNDER THE AGE OF 18 MUST BE ACCOMPANIED BY A PARENT OR AN AUTHORIZED ADULT
If your child needs medical services and you are unavailable, you must give us permission as a parent. It is the law. A child may be treated with parental consent when a physician determines a true emergency exists. This means that the child needs immediate care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child's life or health.
This form is a legal document with which you may appoint relatives, friends, teachers, clergy, and/or neighbors (anyone who is over 18 years of age) to be responsible for your children. It is especially important to prepare this form for occasions when you know it will be hard to contact you. This form will be kept in your child's chart until you make any changes. Sometimes, your child may need care from us that is not emergent. This form allows you to prepare for times when you are back at work, on a vacation, or just hard to reach. This is a legal document. With this form, you may appoint relatives, friends, teachers, clergy, and/or neighbors, anyone who is over the age of 18 years of age to be responsible for your child/children when you are away. This form will be kept in your child's chart with the names of the adults that you have authorized. You can addendum this at any time.
⚠️ Electronic Signature Notice: By typing your full name below, you are creating a legally binding electronic signature.
Wellness Visits vs Office Visits/Sick Visits
Office Visit: This is an office visit for any diagnosis that requires ongoing care (diabetes, cholesterol, blood pressure, etc.)
Sick Visit: This is an office visit for acute care or for a chronic illness/issue.
Wellness Visit/Physical: This is an office visit for a routine physical exam or a yearly wellness exam.
Well-Woman Visit: At a well woman visit, the patient sees her PCP for an annual checkup with or without an annual pelvic exam. Please note that if you have your pelvic exam done with an OB/GYN, your insurance may not cover this service at your physical exam/with another provider.
Well Child Visit: A pediatrician or primary care provider (PCP) performs a physical exam, hearing and vision screening, developmental behavioral assessment, preventative guidance, lab test (if needed or indicated), and administer immunizations for your child. Most plans today are not subject to plan deductibles, and/or a copayment. It is the responsibility of the patient or guarantor to know and understand the insurance plan benefits related to not only the well child visit, but also to the administration of vaccines.
This preventative care benefit is usually provided for children through age 21, at certain intervals if your plan is covered under the Affordable Care Act (ACA). If your plan has not implemented the ACA, your child may be covered for well child visits until age 6.
During the well child visits, your child's PCP will recommend immunizations and other related services that are based on the guidelines established by the American Academy of pediatrics. These additional services, other than immunizations, may require a copayment or be subject to additional benefit limits. The recommendations are standard practice for our office to achieve. Our level of standard care, as we feel they are of benefit to the patient and are useful diagnostic tools in treating pediatric patients.
Well Visit/Office Visit/Sick Visit: This is a combination visit of a routine physical exam and an acute or chronic issue that is addressed. For example, if you are scheduled for a wellness exam and are also sick or need to discuss additional medical diagnosis, or need a medication refill, then this service is outside the scope of the wellness exam and may be subject to a co-pay, deductible, and/or co-insurance.
The insurance company that you choose writes the guidelines that we are contractually obligated to follow; therefore, you may have an additional co-pay, deductible, and/or co-insurance payment due at time of service.
You must acknowledge this policy
Prescription Policy and Medication Guidelines
OUR OFFICE DOES NOT CALL IN ANTIBIOTICS WITHOUT BEING SEEN
Refill: Call your pharmacy and request a refill. A patient must be seen prior to any new prescriptions.
Process: For a refill to be processed, an office staff member will need to verify the prescription, ensure the patient is up to date on appointments, and verify the refill is appropriate. For all maintenance medications you MUST be seen at least twice per year, once for an annual appt and then for a 6 month medication follow up. 3, 6, or 9 month follow-ups are required as proper prescription monitoring protocol and this is up to the provider's discretion and dependent on the type of medications you are on. These guidelines are regulated by the Drug Enforcement Association and the Department of Public Safety. Many prescriptions require monitoring of body functions such as but not limited to labs, blood pressure, and vitals for your own safety.
Timeline: Prescriptions take 48-72 hours to be processed and refilled. Controlled substances can take longer due to researching the patient's chart & DEA monitoring. Requests for the same day or walk-in refills will not be honored.
Staff Treatment: Harassing and/or any unprofessional behavior toward our staff will not be tolerated and could lead to termination of our relationship.
After Hours: There will be no refills after hours, on the weekend, or on holidays by the on-call provider. The on-call provider is for emergencies only and a $25 fee will be assessed.
Allergic reactions: If you think you are having an allergic reaction to medication call 911, and/or proceed immediately to the nearest emergency room. Some medication allergies can be very serious and need immediate attention.
Medication Changes: Any changes or adjustments to your medication treatment plan will not be made over the phone. An APPOINTMENT is required, and any changes will be noted in your chart.
Early Refills/Lost Medications: If your prescription runs out early for any reason, Gruene Lake Medical will NOT prescribe extra medication for you or give you an early refill. If you run out early, you will have to wait until the next prescriptions are due.
Triplicates / Controlled Substances: For triplicate prescription, a patient must be seen every 90 days. An attempt to obtain additional medication by another provider can be considered attempting to abuse narcotic prescriptions and may be referred to legal authorities. For lost or stolen triplicate medication, a police report will be required. Controlled Substances can interfere with driving, operating machines, and overall judgment. There is to be no alcohol use while on a controlled substance. A patient should fully understand the risks of performing these actions while on the recommended dosage can also lead to addiction and cause the medication to become less effective. Controlled substances can adversely affect babies, infants, and a pregnant woman's fetus. Please notify your healthcare provider if you are pregnant or plan on becoming pregnant. Keep all medications in a safe place away from children. By signing below, you acknowledge this policy and agree not to give off your controlled substances to anyone else and to fill your prescription through only one pharmacy. You also understand and agree that random urine drug screens can be ordered by your physician and if you decline this, it will result in termination from practice and further refill.
I have read the above policy, and I am aware of the necessary steps and timeline for prescription refills. I understand my level of general responsibility in regulating and watching my medications. I further understand that Gruene Lake Medical has not only the right to not refill my medications, but also to terminate the physician-patient relationship.
You must acknowledge this policy
Financial Policy
Thank you for choosing Gruene Lake Medical as your primary care provider. We are committed to providing you with quality and affordable health care. Please read our financial policy carefully and let us know if you have any questions.
Insurance: We participate in most PPO insurance plans. (We do not accept HMO policies) If you are not insured by a plan we are in network with, payment in full is expected at each visit. If you are insured by a plan we are in network with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
Financial Authorization: I authorize all payers to pay directly Anna Boecker MD, PA for services provided. I assign Anne Boecker MD, PA my right to receive payment from third party payers. Third party payers include anyone from whom benefits are or may become payable to me for services provided.
Co-payments, deductibles, co-insurance: All co-payments, deductibles and/or co-insurance must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect from patients can be considered fraud. Please help us in upholding the law by paying your co-payment, deductible or co-insurance at each visit. We accept cash, check and credit/debit cards as well as HSA cards. If paying with a credit/debit/HSA card, our payment processing system charges a surcharge of approximately 3.52%.
Private Pay/Self Pay: Private pay patients are responsible for paying the full cost of medical services, treatments or procedures. Payment in full is expected at the time of service for all private/self pay patients. As a courtesy, Gruene Lake Medical offers a 30% discount for all private/self pay patients. If paying with a credit or debit card, our payment processing system charges a surcharge of approximately 3.52%.
Non-covered services: Please be aware that some or all the services you receive may be non-covered or not considered reasonable or necessary by your insurance company. You may be asked to pay for these services in full at the time of service. Services that have been submitted through a claim that were considered non-covered by your insurance company are your responsibility. You may appeal against the claims denied by your insurance company by following the Insurers' directions listed on your Explanation of Benefits (EOB).
Proof of Insurance: All patients must complete our patient information form before seeing a provider. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information at least 48 hours before your appointment, you may be responsible for the entire balance of a denied claim or subject to self-pay rates. (self pay rates are due at time of service)
Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
Coverage changes: If your insurance changes, please notify us at least 48 hours before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
Missed appointments: Our policy is to charge for any appointment(s) not canceled within 24 hours. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your scheduled appointments or cancelling at least 24 hours in advance.
Missed appointment fees: Office Visits: $25.00 | Physical/Wellness Visits: $50.00 | Nurse Visits: $15.00
You must acknowledge the financial policy
Patient Portal User Agreement
REMINDER: THE PORTAL IS NOT FOR EMERGENCIES - IF YOU FEEL THAT YOU NEED EMERGENT CARE PLEASE CALL 911 AND DO NOT LEAVE A MESSAGE ON THE PORTAL.
Portal messages are NOT monitored after hours, on the weekends, and no holidays. If you need to get a hold of your provider, please call the on call service @ 512-323-5465 to have your provider paged.
Gruene Lake Medical is pleased to provide a Patient Portal in partnership with eClinicalWorks for the exclusive use of patients in our practice. The portal is designed to enhance communication between you, the patient and our wonderful providers. We strive to keep all the information in your records correct and complete. If you identify any discrepancy in your records, you agree to notify us immediately, and agree to provide factual and correct information.
The Portal is NOT intended to provide Internet based diagnostic medical services, and limitations apply:
- No Internet-based triage and treatment requests. Diagnosis can only be made, and treatments rendered after the patient is SEEN by a medical provider in our office.
- If your questions exceed our 3-question limit for the same condition you will be asked to make an appointment to discuss.
- Each patient should have their own portal account. Questions and/or requests should be made via that patient's account so proper documentation is accounted for and recorded properly.
- No emergency communication or services. Any emergencies should be handled by calling the office directly, going to an urgent care clinic or emergency room or calling 911.should the emergency be life threatening.
- No requests for narcotic/controlled medications will be accepted.
- No requests for new prescriptions or refills for conditions for which you are not being treated by our clinic will be accepted.
- It may take 72 hours to receive a response to an email/portal request. If you do not receive a response within 72 hours you should contact the office at (830)627-2700.
- If you lose your password or username, you may request a new one through the web portal.
- Always remember to log out your browser when you are finished accessing the portal. YOU SHOULD NEVER USE A PUBLIC COMPUTER TO ACCESS THE PATIENT PORTAL.
Please download the HEALOW app on your smartphone and use the practice code of HAGGDD to start using your portal and navigate through your medical records making sure of its accuracy.
I acknowledge that I have read and fully understand this consent form. I have been given the risks and benefits of the patient portal and agree that I understand the risks associated with online communications between Gruene Lake Medical and myself, and consent to the conditions outlined herein. I know that using the patient portal is entirely voluntary and will not impact on the quality of care I receive should I decide against using the patient portal. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that Gruene Lake Medical may impose for online communications. I have been given an opportunity to ask questions related to this agreement and all my questions have been answered to my satisfaction. I also understand this consent is valid for one year.
You must acknowledge the portal agreement
