South Texas Foot Specialist
|
|
|
- Felicia Green
- 6 years ago
- Views:
Transcription
1
2 South Texas Foot Specialist Mark Sands, DPM Jeffrey Baxter, DPM Bernabe Canlas, DPM Brett Smith, DPM 119 E. Edgewood Friendswood, TX FINANCIAL POLICY Tel: (281) Fax: (281) Thank you for choosing us as you re for your podiatry needs. Our goal is to provide you with highest quality care at an affordable cost. To make our services available to as many patients as possible on an affordable basis, we have adopted the financial collection policy outlined below. We ask you to read the policy carefully and sign prior to any treatment. WE MAY ACCEPT ANY ASSIGNABLE INSURANCE WITH APPLICABLE COVERAGE. WE OFFER FINANCIAL ASSISTANCE (ACA DISCOUNT) UNDER OUR INDIGENCY POLICY TO ALL ELIGIBLE PATIENTS ON CASE TO CASE BASIS FULL PAYMENT IS DUE AT TIME OF SERVICE UNLESS ARRANGED OTHERWISE WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD, AMERICAN EXPRESS CARD, AND DISCOVER. Dishonored checks will be charged back to the patient's account with a service fee of $ Dishonored checks not redeemed within 20 working days of written notice to the maker will be referred to the prosecutor for collection. We do not accept post-dated checks. Regarding Insurance We accept assignment of most insurance benefits at our discretion. A valid insurance card, policy/plan number is needed to verify coverage. As a courtesy to our patients, verifiable and assignable insurance will be billed by our office. However, you will be personally responsible for your account balance regardless whether or not if your insurance will pay for your total balance of your claims, unless you're eligible for discounts under our indgency policy pre-determined before the services are rendered. Your insurance policy/employee benefits plan is a contract between you and your insurance company/employee benefits plan. We are not a party to that contract. Regarding Discount If eligible, you may qualify for certain discounts, reduction or waiver of deductibles, coinsurance and co-pay to any eligible patients based on medical needs and ability to pay, on a case-by-case basis under our Corporate Indigency Policy in accordance with applicable federal and state laws. You may apply for financial indigency discount assistance by asking our staff to determine if you're eligible. Regarding Surgeon and Facility Charges We will disclose to every patient our charges as clearly as practically possible before your medical procedures if it is known to us. Please feel free to ask our staff if you have any questions about charges and your payment responsibilities. Please be advised, your insurance company requires us, your physician, to file services separately from the surgical facility/hospital where services are rendered along with the anesthesiologist, diagnostic labs, radiologists, pathologists, and any other entity involved in your surgery. If you have any questions about your surgical facility bills, please direct your questions to that surgical center. While we don t anticipate any unforeseeable circumstances, we have no control over any such event(s) that may arise. Should you require additional medical or surgical care in any event of the post surgical complications and reactions, you may incur additional expenses at this facility or outside this facility, such as a hospital. Regarding PPO and HMO Network Participation You may have the choice to choose a physician or surgical facilities with or without PPO or HMO participation under different insurance coverage and benefits levels. We are dedicated to providing the highest quality care to every patient, however we have no power to change your insurance coverage or network limitations. Most health care plans or insurance policies may provide coverage to non-ppo providers and facilities, but at lower percentage of insurance reimbursement. Although it is your responsibility to verify your insurance coverage for non-ppo/hmo providers, we will always disclose to you as to our participation status with your insurance plan. We also provide financial assistance or discount for high deductibles and coinsurance through our Corporate Indigency Policy in accordance with applicable federal and state laws, on a cast by case basis. Most health plans or Insurance Polices may have coverage for out-of-network providers or facilities, but at different or lower percentage or level of reimbursement rates. We will verify your insurance coverage and obtain pre-certification if applicable for all services as a courtesy to you before your treatment. Please understand that verification of insurance is not a guarantee of insurance payment. ERISAclaim.com Rev. 01/03/2009, Copyright, Jin Zhou, DC
3 Diabetic Medicare Patients In order to file your claim for Routine Foot Care we must have the date you last saw your diabetic doctor, within 6 months of treatment. HMO Patients You are required to obtain your own referral from your primary care doctor prior to your visit. Medical Records Release/Copying Please allow 48 hours for requested medical records. We charge $8 per x-ray sheet copies. We do not give out the original x- rays, they remain in your permanent medical record. Disability/FLMA Forms Due to the time and length of these forms, we charge a $10 for the first set of disability paperwork. There will be a $5 charge for each additional request. Refunds/Credits Please notify us in the event that you have a true credit and we will send you a check for that amount. Checks are issued on the 15 th and last day of each month. We do not refund, credit or take back any supply given. Unfortunately, every supply doesn t work for every patient. Compliance & Disclosure under Texas Occupations Code - Section In compliance with section of the Texas Occupations Code, I consent that I have been informed of the following information. The choice of doctor or facility I am being referred to is solely based on the quality and safety of care, reputation, and patient satisfaction. I recognized my rights with respect to in-network or out-of-network coverage. My attending doctor(s) and/or clinic (facility) have disclosed to me at the time of initial contact and at the time of referral: (A) his or her affiliation, if any, with the doctor or facility for whom I, the patient, am being referred and (B) that he/she will receive, directly or indirectly, remuneration for referral. It is my request to exercise my right of freedom of choice for the provider(s) and facility under the in-network or out-of-network coverage as provided by my health plan, in compliance with all applicable federal and state laws, Medicare, ERISA, PPACA and the section of of the Texas Occupations Code. Dr. Mark Sands Facility(s) with affiliation and remuneration: Houston Physician s Surgery Center Houston Physician s Hospital Houston Physician s Imaging Center John West Physical Therapy One Step Diagnostic Imaging Center Dr. Jeffrey Baxter s Facility(s) with affiliation and remuneration: Houston Physician s Surgery Center Houston Physician s Hospital Houston Physician s Imaging Center One Step Diagnostic Imaging Center Dr. Bernabe Canlas s Facility(s) with affiliation and remuneration South Shore Surgical Center You Responsibility for Cooperation If we accept your insurance assignment as a form of payment for reimbursement, you agree to timely cooperate with your insurance company or health plan in the course of claim processing, such as insurance inquiries, requests for additional information, claims status verification or any inquiries for the purpose of your claim processing. You also agree to notify us immediately of any insurance inquiry or request for additional information and provide us with a copy of any documentation received from the insurance company or submitted to insurance company from you. Payment for each visit is due at the time of the visit, unless otherwise discussed prior to treatment. you. We are committed to serving you with highest quality care possible at an affordable cost. Our staff is ready to help If you have any questions regarding our financial policies, please do not hesitate to ask. We thank you for your cooperation. I have read the Financial Policy. I understand and agree to this Financial Policy. X Signature of Patient or Legal Guardian Patient Name (print) Date ERISAclaim.com Rev. 01/03/2009, Copyright, Jin Zhou, DC
4
5
6
7
8
Coastal Foot and Ankle Associates
Coastal Foot and Ankle Associates HELLO! WELCOME TO OUR OFFICE! Please print the following information. This information is important for our records and your health. DATE: Patient Name: Birthdate: _ Age:
Advanced Podiatry. W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted.
W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted. Date How did you hear about us? (Be Specific Please) First Name Last Name
Gonzales Healthcare Systems Policy
Gonzales Healthcare Systems Policy Subject: Financial Policy and Healthcare Transparency Purpose: To provide affordable and quality healthcare to our community. Therefore, it is essential that we establish
Medical Information Release Form (HIPAA Release Form) Patient Name: Date of Birth: / / MR #: If minor, Parent/Guardian Name: Release of Information I authorize the release of information including diagnosis,
MasterCare Physical Therapy, Inc.
Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
New Patient Paperwork Current Insurance Card Valid Driver s License It is also important
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az
Eye Physicians & Surgeons of Arizona 6677 W. Thunderbird F-101 10603 N. Hayden Rd. H-100 Glendale, Az. 85306 Scottsdale, Az. 85260 George R. Reiss, MD Shamil S. Patel, MD Vinay M. Dewan, MD Christina M.
DR. IRFAN I. WADIWALA
DR. IRAN I. Board Certified Surgeon X (281) 807-9702 E- AIL ADDRESS: PCP: PATIENT INORATION Patient s last name: irst: iddle: q r. q rs. q iss q s. arital status (circle one) Single / ar / Div / Sep /
Welcome! Warren Parkway Suite 306 Frisco, TX PlastiksForKids.com. Please remember to bring: New Patient Paperwork
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. All appointments are on Monday afternoons. Dr. Stiles operates at the Pediatric Surgery Center. Plastiks
Welcome, If you have any questions about these policies and procedures, please ask one of our staff members for help.
Welcome, Thank you for choosing our practice for your orthopedic healthcare needs. On behalf of everyone at South Shore Orthopedics, LLC we welcome you to our practice. We strive to offer comprehensive,
A SAMPLE FINANCIAL POLICY SHEET
A SAMPLE FINANCIAL POLICY SHEET Our Practice Financial Policy In order to reduce confusion and misunderstanding between our patients and the practice we have adopted the following financial policy. If
This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your benefits can be found.
BlueOptions Schedule of Benefits Plan 03766 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where more detailed information
The Insurance Plans of Choice for Medicare Supplemental Coverage
The Insurance Plans of Choice for Medicare Supplemental Coverage Philadelphia American Life Insurance Company P.O. Box 4884 Houston, TX 77210-4884 POLICY FORM NUMBERS: MS.A.PAL.AR, MS.C.PAL.AR, MS.D.PAL.AR,
PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip
PATIENT INFORMATION - 2018 Patient Name: Last First Middle Initial Address: Street or P.O. Box City, State Zip of Birth: / / Race: Gender: Male Female Social Security #: Marital Status: Single Married
Financial Policy Guidelines
Financial Policy Guidelines Welcome to The Women s Group of Northwestern. We strive to provide you with excellent medical care and our goal is to make your visit as convenient as possible. Please read
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP
BlueOptions Prime EPO
BlueOptions Prime EPO Schedule of Benefits Plan 03768 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where more detailed
Catherine A. Casteel, DPM 7501 Lakeview Parkway, Ste. 135 Rowlett, TX Phone Fax
Catherine A. Casteel, DPM Authorization to Leave a Voicemail Please provide number(s) ONLY IF you approve us to leave DETAILED information related to appointments, billing, test results, diagnosis, and
Lakeside Foot & Ankle Center Karsten Weber, DPM * Alex Stirling, DPM* Nicole Hancock, DPM
Karsten Weber, DPM * Alex Stirling, DPM* Nicole Hancock, DPM Patient Information Name: Date of Birth: Sex: Street Address: City: State Zip Mailing Address (if different) City: State Zip Phone # Cell Phone
2018 CareOregon Advantage Star (HMO) Summary of Benefits
2018 Summary of Benefits For Oregon counties: Clackamas, Columbia, Multnomah and Washington H5859_1099_CO_3018v3 CMS ACCEPTED CAREOREGON ADVANTAGE STAR (HMO) (A Medicare Advantage Health Maintenance Organization
FCSRMC 2017 HEALTH SCHEDULE OF BENEFITS
FCSRMC 2017 HEALTH SCHEDULE OF BENEFITS BlueOptions Plan 05772 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where
ELIGIBILITY INFORMATION YOU NEED TO KNOW
EMPLOYEE BENEFITS PLAN YEAR 2017-2018 TABLE OF CONTENTS Eligibility Information You Need to Know 3 Medical Benefits / Premiums 4 Deductible Type / Alternative Prescription Drug Program 6 Arkansas Blue
Dear Plan Participant,
Dear Plan Participant, Each year you have the opportunity to review your current health insurance benefits and make changes to these benefits for the upcoming plan year. This year s open enrollment period
Welcome! 7000 W. Plano Parkway Plano, TX Please remember to bring: New Patient Paperwork. Current Insurance Card
7000 W. Plano Parkway Plano, TX 75093 SW corner of Plano Pkwy & Marsh Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of
PROFESSIONAL ORTOPEDIC ASSOCIATES PHYSICAL THERAPY NOTICE OF PRIVACY
PROFESSIONAL ORTOPEDIC ASSOCIATES PHYSICAL THERAPY NOTICE OF PRIVACY Attached please find POA S Notice of Privacy Practices. Your name and signature on this cover sheet indicate that you have received
Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:
Center of Excellence in Spinal Care Patient Information Patient Name: Patient Date of Birth: Today s Date: Current Age: Sex (Circle One) Male Female Patient Social Security Number: If Patient is a minor
Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name)
Patient Name Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name) Date of Birth: / / Age: Sex/Gender: Address: / / / (Street/PO Box) (City) (State) (Zip Code) Phone
GEORGIA. CIGNA health savings plans. Health and Pharmacy Benefits c GA 07/ CIGNA
GEORGIA Individual & Family Plans CIGNA health savings plans Health and Pharmacy Benefits PLAN comparison 822163c GA 07/10 2010 CIGNA CIGNA HealthCare plans, offered through Connecticut General Life Insurance
CIGNA open access value plans Sm TEXAS. Health and Pharmacy Benefits b TX 07/ CIGNA
TEXAS Individual & Family Plans CIGNA open access plans CIGNA open access value plans Sm Health and Pharmacy Benefits PLAN comparison 827695b TX 07/10 2010 CIGNA CIGNA HealthCare plans provide coverage
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/fi or by calling 1-800-542-9402.
FREQUENTLY ASKED QUESTIONS (DESIGNED FOR GOOSE CREEK CONSOLIDATED INDEPENDENT SCHOOL DISTRICT)
FREQUENTLY ASKED QUESTIONS (DESIGNED FOR GOOSE CREEK CONSOLIDATED INDEPENDENT SCHOOL DISTRICT) What is NexStep? NexStep is underwritten by Fidelity Security Life Insurance Company (Kansas City, Missouri)
7541 US HWY 87 E, Suite #1 San Antonio, Texas (210) PATIENT S EMPLOYER PLEASE CIRCLE ONE :
7541 US HWY 87 E, Suite #1 San Antonio, Texas 78263 (210) 648-9900 PATIENT S EMPLOYER PLEASE CIRCLE ONE : PPO POS HMO HRA HSA CHOICE PLUSE HEALTH SELECT OTHER NOTICE OF PRIVACY I have reviewed Beaver
SUMMARY OF BENEFITS. Montgomery College Open Access Plus Coinsurance Plan. Connecticut General Life Insurance Co. Notice of Grandfathered Plan Status
SUMMARY OF BENEFITS Connecticut General Life Insurance Co. Notice of Grandfathered Plan Status This plan is being treated as a grandfathered health plan under the Patient Protection and Affordable Care
Patient Guide to Billing and Insurance
Patient Guide to Billing and Insurance Patient Account Payment Policies December 2017 Lexington Clinic Central Business Office Payment Policies Customer service...2 Check-in...2 Plan participation, network
SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Health Savings Account Open Access Plus
SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. RADCO Health Savings Account Open Access Plus General Services In-Network Out-of-Network Physician office visit Primary Care Physician (PCP) Physician
Family Clinic 808 W.W. Ray Circle Bridgeport, TX / phone 940/ fax. Financial Policy
Financial Policy Our staff would like to welcome you to our clinic and thank you for choosing us for your medical care. The following is an explanation of our financial policies. Our clinic is contracted
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-585-343-0055 ext. 6415. Important Questions Answers
TENNESSEE. CIGNA health savings plans. Health and Pharmacy Benefits TN 09/ b TN 07/ CIGNA
TENNESSEE Individual & Family Plans CIGNA health savings plans Health and Pharmacy Benefits PLAN comparison 820920 TN 09/08 820920b TN 07/10 2010 CIGNA CIGNA HealthCare plans, offered through Connecticut
WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
Page 1 of 4 WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Date: Dr: Chart #: Patient s Name: First MI Last Patient s
The Value of Health Plan Networks
The Texas Association of Health Plans Representing health insurers, health maintenance organizations, and other related health care entities operating in Texas. The Value of Health Plan Networks What are
UnitedHealthcare Choice Plus. United HealthCare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus United HealthCare Insurance Company Certificate of Coverage For the Definity Health Savings Account (HSA) Plan 7PC of East Central College Enrolling Group Number: 711369 Effective
$0 See the chart starting on page 2 for your costs for services this plan covers.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.chchealth.org/affordablehealth/planbrochure/silver.aspx
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Checkup on Health Insurance Choices
Page 1 of 17 Checkup on Health Insurance Choices Today, there are more types of health insurance, and more choices, than ever before. The information presented here will help you choose a plan that is
***2017 FORMS ARE PENDING TDI APPROVAL***
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
Is there an out of pocket limit on my expenses? Even though you pay these expenses, they don t count toward the out-ofpocket
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-877-988-1918.
Individual Insurance
Health Insurance Health Insurance against loss by illness or bodily injury. Health Insurance provides coverage for medicine, visits to the doctor or emergency room, hospital stays and other medical expenses.
The Value of Health Plan Networks January 28 th, 2016
The Texas Association of Health Plans The Value of Health Plan Networks January 28 th, 2016 JAMIE DUDENSING, CEO The Texas Association of Health Plans The Texas Association of Health Plans (TAHP) is the
2018 Enrollment Election Form
2018 Enrollment Election Form Accepted 2018 Enrollment Election Form Please contact AllCare Advantage if you need information in another language or format (Braille). To Enroll in AllCare Advantage, Please
of all prescription and non-prescription medications or supplements
Diplomate, American Board of Podiatric Surgery Fellow, American Board of Foot and Ankle Surgeons 1201 Medical Plaza Court Granbury, Texas 76048 817-578-8555 brazosfootandankle.com Dear Patient: Thank you
Yes, written or oral approval is required, based upon medical policies.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.uhc.com/calpers or by calling 1-877-359-3714. Important
SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1
SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. RADCO Open Access Plus - Plan 1 General Services In-Network Out-of-Network Physician office visit Primary Care Physician (PCP) Physician Office Visit
Summary of Benefits and Coverage
Summary of Benefits and Coverage Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
Board of Huron County Commissioners : HSA
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions
2009 Rates Enclosed MEDICARE SUPPLEMENT INSURANCE. From the Name You Can Trust for Stability and Value
2009 Rates Enclosed MEDICARE SUPPLEMENT INSURANCE From the Name You Can Trust for Stability and Value IMPORTANT NOTE! A policy cannot be issued without all the required forms. For prompt application processing,
Keystone 65 Choice Point-of-Service Rider An Addendum to Your Evidence of Coverage
Keystone 65 Choice Point-of-Service Rider An Addendum to Your Evidence of Coverage Effective January 1, 2008 through December 31, 2008 1-800-645-3965 TTY/TDD: 1-888-857-4816 Seven days a week 8 a.m. 8
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
PATIENT INFORMATION EMERGENCY CONTACT
Phone (614) 682-5095 Fax: (614) 891-6533 www.ohioplasticsurgeryspecialists.com PATIENT INFORMATION Name Birth Date Age (First, Middle Initial, Last) Address City State Zip Home Phone ( ) Work Phone ( )
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address: Phone: Insured/Responsible Party Patient Information Name: Address;
CARECOUNSEL TIPS SELECTING A HEALTH PLAN. Step 1: Gather Basic Information. Step 2: Assess Your Needs
SELECTING A HEALTH PLAN Choosing between health plans is no longer a simple matter. As a healthcare consumer, it s important that you educate yourself about the various health plans available to you. You
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org/go/state or by calling 1-888-762-8633 Important
Medical Plan Summary: PPO Core Plan
Medical Plan Summary: PPO Core Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
AvMed Network: $1,500 individual / $3,000 family Doesn t apply to preventive care. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org or by calling 1-800-376-6651. Important Questions
HOW TO CHOOSE A MEDICAL PLAN MOTT COMMUNITY COLLEGE
HOW TO CHOOSE A MEDICAL PLAN MOTT COMMUNITY COLLEGE Chadd Hodkinson SET SEG Employee Benefit Services Account Executive The content in this presentation is informational. Each employee should review the
Registration Form. City: State: Zip: Birthdate: Marital Status: M S W D. Patient Employer: Occupation: Employer Address: Emp.
Registration Form Patient Information Name: Address: SS#: Phone: City: State: Zip: Sex: F M Birthdate: Marital Status: M S W D Patient Employer: Occupation: Employer Address: Emp. Phone: Whom may we thank
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplan.memorialhermann.org or by calling 1-888-594-0671.
Personal Finance, 6e (Madura) Chapter 12 Health and Disability Insurance Background on Health Insurance
Personal Finance, 6e (Madura) Chapter 12 Health and Disability Insurance 12.1 Background on Health Insurance 1) Health insurance protects net worth by minimizing the chance that you will have to reduce
SCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center
SCHEDULE OF BENEFITS UNIVERSITY OF PITTSBURGH PPO PLAN - Applies to PA Child Welfare Resource Center The following Schedule of Benefits is part of your Certificate of Coverage. It sets forth benefit limits
Premier Obstetrics and Gynecology
, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s
You must pay all of the costs for these services up to the specific deductible amount before the plan begins to pay for these services.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-552-9159. Important Questions
COSE MEWA : HRA W RX
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions
SUMMARY PLAN DESCRIPTION SAMPLE COMPANY
This document is a sample of the basic terms of coverage under a Choice Plus product. Your actual benefits will depend on the plan purchased by your employer. SUMMARY PLAN DESCRIPTION COMPANY 0000-000000
K A R A N J O HA R, M.D.
P: : REGISTRATION FORM - MAJOR MEDICAL Last Name: First and Middle Name: Social Security #: Birthdate: Age: Sex: F M Marital Status: M S D W Home Address: City: State: Zip: *Does the above address, match
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/01/ /31/2019
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/01/2019-12/31/2019 PLUMBERS LOCAL 24 WELFARE FUND BUILDING TRADES DIVISION APPRENTICES Coverage
Out-of-Network Law (OON) Guidance (Part H of Chapter 60 of the Laws of 2014)
Health Plan Disclosure Requirements Out-of-Network Law (OON) Guidance (Part H of Chapter 60 of the Laws of 2014) 1. Provider Directory: Insurance Law 3217-a(a)(17) and 4324(a)(17) and Public Health Law
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
Important Questions Answers Why this Matters: Network: $3,500 Individual $7,000 Family Non-Network: $10,000 Individual $20,000 Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.inhealthohio.org or by calling 1-800-580-8502. Important
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS What is the Major Medical Complement? The Major Medical Complement is an insured product designed to help pay deductibles, coinsurance and co-payment amounts for those with high
KNOW your BENEFITS. Do you have questions about your medical or prescription drug coverage?
2015 BENEFITS GUIDE We are pleased to announce that we will be renewing our medical and pharmacy benefit plans with Florida Blue for 2015. This Benefit Guide provides important information and details
UnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 21D of Big Walnut Local School District Enrolling Group Number: 753271 Effective Date: January 1, 2016
Your Options: You may choose one of the following options.
October 17 to November 4, 2016 Benefit Information for Non Permanent Employees Working an Average of 30 Hours/Week (For employees who only qualify for Bronze Plan) The Affordable Care Act (ACA) requires
NIA Magellan i Frequently Asked Questions (FAQs) For Blue Cross of Northeastern Pennsylvania Providers
NIA Magellan i Frequently Asked Questions (FAQs) For Blue Cross of Northeastern Pennsylvania Providers Question GENERAL Why is Blue Cross of Northeastern Pennsylvania implementing an outpatient imaging
Associates in Plastic & Aesthetic Surgery PATIENT REGISTRATION
PATIENT REGISTRATION Name Date Date of Birth Age Social Security No Demographics Male Female Single Married Divorced Widowed Reason for your Visit Who referred you to this office Doctor Patient Web Site
Patient Registration WELCOME TO OUR OFFICE
Patient Registration WELCOME TO OUR OFFICE Date of Birth: Home Address: Apt / Unit: City: State: Zip: SSN: Telephone: Home: Cell: Work: Email: Marital Status: Name of Spouse / Partner: Preferred method
Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:
First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
Patient Information Form
Patient Information Form General Information Today s date / / Patient s name Last name First name Middle initial Address Street City State Zip code # ( ) # ( ) Work # ( ) Preferred telephone contact Work
Charles T. Murphy, DPM. Podiatric Medicine and Surgery. Patient Registration
Charles T. Murphy, DPM Podiatric Medicine and Surgery Patient Registration Patient Name: Billing Address: Permanent Address: Responsible Party Name: City, State, Zip: City, State, Zip: Home Phone: ( )
Assurant HSA Plan. Benefits
Assurant HSA Plan The Assurant HSA plan pairs a high deductible health plan with a tax-free health savings account (HSA). Since premiums are usually lower with a high deductible health plan than with a
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Small Group HMO Coverage Period: Beginning on or after 05/01/2013
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org. or by calling 1-800-376-6651. Important Questions
State of Wisconsin: Arise IYC Health Plan Coverage Period: 1/1/17-12/31/17
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions
Tri-County Schools Insurance Group: Basic Plan Coverage Period: 01/01/ /31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.tcsig.com or by calling Delta Health Systems at 1-800-464-7627.
2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX
2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX H0062_19_7952SB_002_M_Accepted 09072018 This booklet provides you with a summary of what we cover