Forms/Policies


Patient Forms

The following new patient forms are required forms for your first visit. We have conveniently placed our office forms online for you to download and fully complete at home. Please bring the completed forms to your appointment, along with your insurance card, photo ID and co-payment.


Forms to download:

Adults (18+ years):

  1. Patient Demographics.pdf
  2. Financial-HIPPA Authorization.pdf
  3. Adult Health History.pdf
  4. Patient Consent to Treatment.pdf
  5. Health Information Authorization.pdf
  6. NOTICE of Privacy.pdf


Child (Birth-18 years old):

  1. Pediatric_Demographics.pdf
  2. Pediatric Health History
  3. Financial-HIPPA Authorization.pdf
  4. Patient Consent to Treatment.pdf
  5. Health Information Authorization.pdf
  6. NOTICE of Privacy.pdf


OTHER FORMS:

    Patient Portal User Agreement.pdf

    Medical Records Release.pdf


Services We Offer:

Dr. Sanford F. White is a Board Certified Physician.  He and his staff provide patient care for  Men, Women & Children (Newborn and up) and for medical problems/conditions of all types.  Additionally he provides:

  • Work, School & Sport Physical Exams
  • Immunizations
  • Women’s Health
  • Contraception Management
  • Minor Surgeries
    • Cosmetic & Medical Skin Care
    • Circumcisions
    • Mole and Wart Removals
    • Laceration Repairs
    • Post-operative management
  • Hospital inpatient care (Dr. White has privileges at the following hospitals)
    • Southern Hills Hospital
    • St. Rose Dominican Hospital (San Martin Campus)
    • Spring Valley Hospital (Newborn care only)
    • Summerlin Hospital (Newborn care only)                                                      

 


Office Policies:

Prescriptions:

How to obtain PRESCRIPTION REFILLS:Refill requests should occur during a follow-up appointment. In unusual circumstances, you may contact your pharmacy first and ask them to send a refill request electronically.

Please allow 48 to 72 hours to process your refill request. If the doctor determines that you need an updated examination to be able to refill your medication the medical assistant will call and assist you with making an appointment. 

Insurance Pre-Authorization for your medication, if required, is a time consuming process so please allow a minimum of 5 days. The pharmacy turn-around time is 72 hours, and then our office needs 48 to 72 hours to complete the request. Please allow the necessary time for us to assist you. 

We will try our best to prescribe generics and/or formulary medications where available; however, it is impossible for us to keep track of every insurance company’s formulary changes. Your cooperation and patience is appreciated.

   

Appointments: 

Call 951-3400 to schedule an appointment.  Once you have scheduled an appointment, download the patient registration forms and bring the completed forms to you appointment, along with your insurance card, photo ID and co-payment.


Payment: 

Payment is due at the time of service.  This includes, but is not limited to co-payments, co-insurance, and deductibles.  We will not send you a bill for these fees.  If for some reason, these fees are not collected at the time of service, a $10 late fee will be added.  Accepted forms of payment are Visa, MasterCard, AMEX, cash or personal check


Returned Check Policy:  

Writing a bad check is against the law.  There is a $50 fee for all returned checks.  If we receive a returned check, you must pay the balance, including the fee, with Visa, MasterCard or cash only.

 

Collection Policy:  

We will make three (3) attempts via phone, e-mail or U.S. mail to notify you of any unpaid balance on your account.  It is important that you keep our office notified of any changes to your personal information (i.e. address, phone number, e-mail address).  If an account remains unpaid after ninety (90) days, the account will be referred to a collection agency and a $45.00 collection fee will be charged.

 

Cancellation Policy: 

Please help us to serve you better by keeping your scheduled appointments.  Missed appointments could cause longer waits for other patients.  Twenty-four (24) hours notice is required for changes to a scheduled well or routine visit.  Two (2) hours notice is required for changes made to a scheduled sick visit.  A $25.00 fee will be charged to your account if proper notice of cancellation is not received.  After three (3) “no call, no show” appointments, further action may be taken. We consider 10 minutes past your scheduled appointment time as late. We may still be able to see you, but you may have to have your appointment rescheduled to a later date and/or time.


© Ensign Family Medicine, LLC 2012