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Name: ___________________________________________
Date: __________________
All obstetrical fees in this office are set
up according to federal regulations and include the following:
1)
Normal obstetrical office visits from prenatal work-up through the six week
postpartum exam.
2) Normal vaginal delivery and physician care during the
postpartum hospital stay.
3) Hemoglobin and urinalysis lab work done in the
office as part of routine prenatal visits.
The package fee does
not include:
1) Extra charge for Cesarean section.
2) Extra
office or emergency room visits or hospital admissions for non-obstetric
reasons or pregnancy complications.
3) Blood work or other specimens sent
to outside laboratories.
4) Ultrasound examinations or fetal non-stress
testing.
5) Epidural anesthesia.
6) Circumcision of male infant.
You can expect to be billed by either this office or elsewhere for the
above services or any others which are incurred for reasons other than normal
pregnancy.
It is very rare for any insurance to pay 100% of all
charges. By the time of your prenatal work-up visit we will have calculated the
approximate amount that you will be responsible for paying for normal
obstetrical care and will determine an amount for you to pay on a monthly basis
(usually at the time of your regular prenatal visit) so it is paid up by your
30th week of pregnancy. Be aware that you may receive a bill from our office
for your portion of any extra services listed above, or if your insurance
company pays a smaller portion than what was promised to our insurance
personnel at the beginning of pregnancy. If the payment is more than estimated
you would then receive a refund check from our office for any excess over the
paid balance.
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. Should they determine you were
ineligible for coverage or you cancel your policy before delivery, you
will be responsible for the entire amount. Your insurance coverage will be
re-verified from time to time during pregnancy.
If you have no
insurance coverage or if it becomes inactive for any reason during pregnancy,
we will set up monthly payments so you can have the package fee paid off by the
30th week of pregnancy. If any additional services are rendered you will
receive a bill for these after delivery. Should you decide you cannot meet this
payment schedule or are unable to do so we will help you secure an appointment
at the OB Clinic of Wake Medical Center.
Any accounts not settled by
three months after delivery (or final insurance payment if coverage is in
force) or termination of services will be turned over either to a professional
credit collector or attorney. We feel our policy is similar to, if not more
equitable and less stringent than, those of most offices locally and
nationally.
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.
3) I assign payment of
insurance benefits to Blue Ridge OB/GYN Associates.
(Printed Name)
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Signature |
Date |
(Printed Name of Witness) |
Signature |
Date |
1. Print this form, then fax or mail
it.
2. Fax: (919) 781-9247
3. Mail Address:
11001 Durant Road,
Suite 100
Raleigh, NC 27614
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