NEW PATIENT FORM
We take all commercial, Medicare, and Medicaid Plans.
Before your first visit, please print and fill out these forms. For your appointment, be sure to bring with you:
Also referred to as approved charge, allowable charge, this is the dollar amount typically considered payment in full by your insurance company along with its network providers. The allowed amount is a discounted rate rather than the actual charge. For example, you visit a doctor who is an in-network provider of your insurance, and the total charge for the visit was $100. Your doctor is required to accept $80 as payment in full for the visit. This is the allowed amount. Your insurance will pay your doctor $80, minus any co-pay or deductible that you may owe. The remaining $20 is considered “write off”, and you cannot be billed for it. If your doctor is not within your insurance network (an out of network provider) you may be responsible for the full charge of $100.
A dollar amount your insurance may require you to pay for an office visit at the time of your appointment. It is required to be paid at every office visit.
The amount that your insurance may require you to pay for covered medical services
After you have satisfied co-payment and/or deductible. It is typically expressed as a percentage (%) of the allowable charge for covered medical services. For example: if the coinsurance is 80/20 your insurance covers 80% of the allowable charge, then you are required to pay the remaining 20% of coinsurance.
A dollar amount that your insurance may require you to pay out of pocket each year
BEFORE your insurance plan begins to make payments for claims. Not all plans require a deductible; therefor always check with your insurance company to see if your plan has any deductibles. Deductibles reset on a renewal date, which is typically January 1st
Healthcare providers who are not contracted with the health insurance plan. Typically, if you visit a provider within your insurance’s network (in-network provider), the dollar amount for the medical services will be less than if you go to an out-of-network provider.
Out-of-Pocket Limit (OOP Limit, Stop-Loss or Coinsurance Limit):
The most you have to pay for covered medical services in a plan year. After you spend this amount on a deductible, co-pay, and coinsurance than will your insurance pay 100% of the costs of covered benefits. Just like the deductibles, out-of-pocket maximum resets with the plan every year.
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.