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Office Policies for
Obstetrical Care
August 14, 2002
Thank you for allowing
us to participate in your care during this very exciting time. We are
all committed to providing you with the best obstetrical care
possible. We will do whatever possible to make your pregnancy a
positive, rewarding experience, with a minimum of complications or
surprises.
This summary of office
policies is designed as a first step toward ensuring a positive
pregnancy experience. We believe that through open and honest
communication, we can ensure that you understand the financial
commitment associated with your pregnancy. We hope this will alleviate
some of the anxiety you might otherwise experience later in your
pregnancy. Please take a few minutes to read the policies outlined in
this letter. We would be happy to discuss any part of these policies
with you. Feel free to ask us questions either prior to returning the
enclosed Patient History, or at your first Obstetrical visit.
Your care will be
managed by Douglas C. Hall, M.D., and Evette F. Hearn, ARNP. These
professionals will manage your care jointly, Dr. Hall will deliver
your baby, and Ms. Hearn will perform your final postpartum
examination. It is anticipated that you will alternate between seeing
Dr. Hall and Ms. Hearn for each of your interim exams.
In the event a C-
Section is required, Dr. Hall will be assisted by Lori J. Hunter,
Certified Registered Nurse First Assistant (CRNFA). Ms. Hunter has
been assisting in surgery for more than twenty (20) year. Her First
Assistant designation is testament to her advanced training and
experience in performing assistant at surgery services..
Dr. Hall does share
call duties with other physicians, on as needed basis, so there is a
possibility that another physician will attend your delivery rather
than Dr. Hall.
Please complete the
enclosed confidential information sheet and Patient History, and sign
the last page of this form. Return these to us in the enclosed
self-addressed envelope at your earliest convenience. We will review
the data and telephone you to set up a convenient time for your first
obstetrical visit.
ESTIMATED CHARGES
FOR ROUTINE OBSTETRICAL CARE:
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Initial Visit to
establish diagnosis of pregnancy
Maternity Care & Delivery (including uncomplicated vaginal
delivery)
Total charge for uncomplicated obstetrical care |
$
135.00
2,300.00
$ 2,435.00 |
|
Additional
charge for Cesarean Section
Surgeon
Surgical
Assistant |
700.00
330.00
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| Total
charge for uncomplicated OB care with C-Section |
$
3,465.00 |
Please understand that
the above amounts represent our charges for uncomplicated
obstetrical care. Complications and certain conditions, such as RH
Negative blood, may require that we perform additional tests and
procedures. Such modifications of our services may require additional
amounts be charged. In addition ,any other conditions which may arise
during your pregnancy, such as colds, infections, etc. will result in
additional charges. You will be expected to pay for your portion of
these additional charges at the time services are rendered.
We understand that
obstetrical care represents a tremendous bill for most patients.
We have therefore designed a payment schedule we believe is fair and
keeps the financial burden of your OB care to a minimum. The
payment schedule provides for an initial payment of $200.00, which is
due PRIOR TO your first visit. The remainder of the routine
charges, detailed above, should be paid in equal monthly installments
which we will calculate and review with you at your first OB
examination. If you have medical insurance which will cover your
obstetrical care, we will contact your insurance company to confirm
coverage and discuss the provisions of your policy prior to
calculating your required monthly payment amount. Our goal is to have
you pay your portion of our charges by the time of your
delivery. This will leave only the insurance company's payment
to be collected after your baby is born.
You are responsible for
the payment of all charges incurred during your obstetrical care. If
you have OB insurance, we will file your insurance claims for you.
These filings will be done immediately after the services are
performed.
Please provide the
following information to allow us to contact your insurance company to
verify your obstetrical insurance and coverage.:
| Named
Insured |
Birth
Date: |
Insured's
Soc Sec #: |
| Patient's
relationship to insured |
|
| Insured's
place of employment |
|
| Insurance
Company Ins Co. Phone # |
(
) |
| Group
Number Insurance policy # |
|
| First
day of your last menstrual period |
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Please send us a
photocopy of your insurance card (front and back) along with this
completed form. This will ensure we have all the information the
insurance needs to answer our questions about your coverage.
Your expected monthly
payments will be calculated when your papers are returned to our
office. Your payments will be calculated based on your estimated due
date and the insurance information (if any) you provide.
PLEASE
NOTE:
Our determination of
whether to accept you as an obstetrical patient is based, in part, on
the requirements of the insurance coverage you currently have (if
any), and on our understanding that you can pay any amounts payable by
you personally with respect to your pregnancy.
It is your
responsibility to advise us of any changes in your insurance during
your pregnancy.
If your insurance
coverage does change during the pregnancy, we reserve the right to
determine, at that time, whether or not to accept the terms of your
new plan, and to recalculate your monthly payment schedule. If it is
necessary to change your monthly payment amount, you will be asked to
sign an acknowledgment of the new payment schedule and of our decision
on whether or not to accept your new insurance plan's terms and
conditions.
In
the event you are unable to agree to the recalculated payment schedule
you will, of course, have the option to go elsewhere for the remainder
of your obstetrical care. If you choose to do so, you will be charged
for the obstetrical services performed to that date, and will receive
a refund of any amounts paid in excess of the charges for the services
rendered. You should be aware that the charges for the services
rendered through the date of your decision to terminate our
relationship may be more than you have paid in through the monthly
installment plan. If this is the case, you would then be responsible
to make an additional payment to satisfy these charges.
Regardless of whether
or not you have insurance coverage, all charges for services rendered
must be paid in full within 60 days of completion of the services. In
the event that your insurance carrier does not make prompt payment for
submitted expenses, this may require you to make payments in addition
to those scheduled. If this is the case, we will continue to work with
you to secure reimbursement from your insurance carrier, and will
refund any later payments received from your insurance company, in
excess of your unpaid balance.
Douglas C. Hall, M.D.,
P.A. reserves the right to charge interest at the rate of 18% per
annum, from the date of service, on all account balances which are not
paid in accordance with the policies described herein.
We have read and understand and agree
to abide by the above policies:
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Patient Signature |
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Signature of Father of baby |
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Patient SS. number |
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Baby's Father's SS. number |
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Date |
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Date |
WE LOOK FORWARD TO SEEING YOU SOON!
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