|
Fees &
Insurance
The doctors serve as specialty consultants for the
following health plans (inquire about others):
- Blue Cross PMD
- HealthStrategies
- VIVA
- Healthsprings of Alabama
- Health Choice
- United Health Care
|
- Private Health Care Systems
- Aetna
- Cigna
- SelectCare
- Seniors First
|
Please bring your health insurance card(s) so we may
verify coverage and photocopy them for our records.
Fees: The office is on a cash basis and fees
for non-emergencies should be paid at the time service is rendered.
If you are covered by a plan that pays office services, you are
responsible at the time of service only for the applicable
co-payment.
If your plan requires an approval or precertification for our
care, we must have this approval available to us at the time of your
visit.
If your insurance company requires filling out a special form,
attach the portion of the billing slip you will receive at the time
of your visit to your insurance form and mail directly to the
company. This provides all the information needed to complete the
claim and payment will thus go to you directly.
Information regarding fees for office and hospital services is
available upon request.
The surgical fee covers all routine post-operative care and
clinic visit; please do not miss post-op checkups because of
anticipated increased financial burdens.
Visa, MasterCard and DISCOVER cards are accepted.
Insurance Information: Payment for services
rendered is to be made as follows: "I request that payment of
authorized insurance benefits be made to Richard W. Waguespack,
M.D., PC, for any services or items
furnished me by the physician or supplier. I
authorize medical information about me to be released to the
Health Care Financing Administration (HCFA), my Insurance Carrier,
and/or its agents any information needed to determine these benefits
or the benefits payable for related services. I am financially
responsible for appropriate deductibles, co-payments, and
non-covered items (which have been explained to me from information
supplied by my carrier). If this account has to be turned
over to an attorney due to delinquency or nonpayment, I will be
responsible for all costs of collection including the court costs
and reasonable attorney fees."
_____________________________________________________
________________ Signature of Beneficiary or Person Signing for
Beneficiary
Date Signed |
_____________________________________________________
________________ Street Address, City, State, Zip of person signing for
Beneficiary
Relationship |
| Reason Beneficiary is unable to
sign________________________________________ |
Dissemination of Medical Information: To
whom may we, as your health care providers, release information
about your medical condition(s)?
______________________________________________
________________
Relationship |
______________________________________________
________________
Relationship |
______________________________________________
________________
Relationship |
______________________________________________
________________ Signature of Patient or Responsible
Party Date
Signed |
Any information provided on this Web site should not be
considered medical advice or a substitute for a consultation with a
physician. If you have a medical problem, contact your local
physician for diagnosis and treatment.
|