Womens Wellness Place Policy Agreement (Page 2 of 2) in pdf

Our practice is committed to providing the best treatment for our patients, and we charge what is appropriate based on

geographic location, physician skill and expertise. You are responsible for payment regardless of any insurance

company’s arbitrary determination of usual and customary rates.

We must emphasize that as a medical care provider, our relationship is with you, not your insurance company.

While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility

from the date the services are rendered. We realize that temporary financial problems may affect timely payment of

your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of

your account.

Returned checks are subject to an additional collection fee of $25. In the event that your account is sent to collection, you

agree to pay all related costs and expenses, including attorney’s fees.

Your yearly preventive exam is provided by your insurance company to check things such as your pap, breast exam,

mammogram and pelvic organs and help you address wellness issues. It does not include services rendered for additional

complaints that need to be addressed, tested for and treated. These will be billed to your insurance as an additional

problem, and you may be subject to an additional copay for these services. We also reserve the right to charge for

renewing medications that we do not regularly prescribe at your yearly exam or that are not gynecologic in nature. If you

need an extended telephone consultation because you can’t schedule an appointment, a fee may be charged for this

consultation. We do not charge for telephone calls to clarify questions on medications, treatment, possible side effects, or

lab results. We appreciate your understanding of this policy.

If you have any questions about the above information, or any uncertainty regarding insurance coverage, PLEASE don’t

hesitate to ask us. We are here to help you. May we also advise you to keep a copy of these forms for your own personal

records. Thank you for your time in carefully reviewing our office financial policy.

I have carefully read the above office policy, as well as understanding and agreeing to the terms and conditions of such.

PATIENT NAME (Please Print)_________________________________________________________

PATIENT SIGNATURE_________________________________________ DATE _______________

Reminder: Please remember your insurance card at the time of your visit so that we may obtain a copy.

Return all necessary forms to our office PRIOR TO YOUR APPOINTMENT to avoid appointment

delays.

INSURANCE INFORMATION

SECONDARY INSURANCE (If Applicable)

PRIMARY INSURANCE

Name: ______________________________________________

Group #: ____________________________________________

Name: ____________________________________________________

Policy #:

___________________________________________

Group #: __________________________________________________

Policy Holder: ________________________________________

Policy #:

__________________________________________________

Relationship: _________________________________________

Policy Holder: _______________________________________________

Policy Holder Date of Birth: ______________________________

Relationship: _______________________________________________

Policy Holder Social Security #: __________________________

Policy Holder Date of Birth: ____________________________________

Address Where Claims are Sent: _________________________

Policy Holder Social Security #: _________________________________

____________________________________________________

Address Where Claims are Sent: ________________________________

__________________________________________________________

I have answered the above information regarding

Does your primary insurance carrier require authorization

my insurance information to the best of my

for:

knowledge, and have contacted my insurance

[ ] Specialist [ ] Consultation [ ] In-Office Test/Procedures?

company to assist me in those questions I was

uncertain about.

What is your annual deductible amount? $ ________________________

Has your deductible been met this year? [ ] Yes

[ ] No

What is your co-pay amount? $ _________________________________

Signature:

__________________________________________

Does your insurance have benefits for:

Well Woman Visit?

[ ] Yes [ ] No

Date: _______________________________________________

How often? [ ] Once per year

[ ] Twice per year

Screening Pap smear? [ ] Yes [ ] No

How often? [ ] Once per year

[ ] Twice per year

C:UsersLaurieDesktopNewPt Financial.DOC

Revised 3/21/2014

Womens Wellness Place Policy Agreement Page 2

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