FINANCIAL AGREEMENT FOR SURGICAL PATIENTS

Name: ___________________________________________ Date: __________________

Like most gynecologists we charge a package fee for surgery and post-operative care. This fee includes:

1) Performance of the surgical procedure and post-operative visits in the hospital.
2) Office visits for post-operative care dating from your hospital discharge through eight weeks after surgery. You will be charged separately for visits and services after eight weeks.
3) Laboratory work performed in the office (fingerstick hemoglobin and dipstick urinalysis). You will be billed separately for any lab work.

This basic fee does not include hospital charges, anesthesiologist's charges, a surgical assistant's fee, medical consultant's fee (should one be needed), or charges for extra non-covered procedures as explained below.

Surgical Assistants:
Depending on the complexity of the procedure, an assistant for the surgeon may or may not be needed. You should be aware that hospital by-laws require an assistant on many major medical procedures. An assistant surgeon is usually one of our own physicians.

Patients With Insurance:
It is unusual for any insurance company to pay 100% of all charges and you are expected to pay the difference between the insurance company's payment and the allowable charge; it could be a very small fixed co-payment or a larger combination of deductible and co-payment of as much as 20- 25%. We can help estimate what this figure will be so you can arrange structured payments at your post-operative visits. Once the insurance company has paid its portion you will be billed for any remainder, or if the payment is larger than expected, you will receive a refund.

Remember that the agreement you have with your insurance company is your responsibility to understand and work out, and that the doctor cannot change the terms of your contract. The final obligation for the bill is therefore yours and not the insurance company's. If for any reason the insurance company fails to pay (if they determine you were ineligible for coverage or they withdraw certification of medical necessity for the procedure, just to name two examples) or they pay less than anticipated we are sorry, but you are still expected to pay the bill. After any payment from the insurance company is received, or within three months after surgery (whichever is sooner), you will be billed and expected to pay the balance. Any accounts not settled by three months from the date of surgery will have help enlisted for collection by either a professional agency or attorney.

Patients Without Insurance:
If you have no insurance benefits you are expected to pay at least half of the estimated surgical fee before surgery and to pay the remainder of the actual fee within three months after surgery. You can divide the fee into equal monthly portions to meet this schedule, if desired, and we can accept payment by MasterCard or VISA.

Should you decide you cannot meet this payment schedule we will help you secure an appointment elsewhere. Just as is the policy for patients with insurance, any accounts not settled by three months after surgery will be turned over either to a professional credit collector or to an attorney.

Non-covered Procedures:
In order to save money, some insurance companies will sometimes refuse to pay for one portion of the procedure while providing coverage for the rest.. As one example, they will often not pay for a tubal ligation which is performed at the same time as an ovarian cystectomy, Cesarean section, or other procedure requiring an abdominal incision. Even though they may cover the procedure separately at another time and place (obviously at much greater cost to themselves and much greater risk to you), they fail to see the sense of doing it concurrently. Should you wish all requested and needed portions of the surgery to be carried out and the insurance company declines payment, then you are expected to pay for the remainder. If we find a different situation at surgery than what was expected and a different procedure is done than what was planned, we will obviously submit charges only for what was actually done.

By your signature below you agree:
1) I have read the above information and had the opportunity to ask questions, and I agree to the payment provisions described therein.
2) I authorize the release of medical information from my office and hospital records to my insurance company as needed to process my claim. A copy of this release is as valid as the original.
3) I assign payment of insurance benefits to Blue Ridge OB/GYN Associates.

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