![]() If your insurance company does not pay within 30 days, you will be responsible for the balance. If your insurance changes, please notify us before or on your next visit so we can make the appropriate changes to help you receive your maximum benefits. We accept MasterCard, Visa, Discover and American Express. Payments can be made in the form of cash, personal check or credit card. In upholding the law by paying your co-payment and/or deductible at each visit. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. This arrangement is part of your contract with your insurance company. Co-payments and deductiblesĪll co-payments and deductibles must be paid at the time of service. Please contact your insurance company with any questions you may have regarding your coverage. Knowing your insurance benefits is your responsibility. If you are insured by a plan we do business with, present your current card at your office visit If you are not insured by a plan we do business with, payment in full is expected at each visit. Ascension St Vincent’s is creating a stand alone Emergency Department off interstate 65 in Pelham. We participate in most insurance plans, including Medicare. (WBRC) - If you live near Pelham you will soon have a much easier time gaining access to emergency health services. Please let us know if you have any questions or concerns. ,Features include: a free-standing tertiary care, pediatric hospital with 40 private inpatient beds and 6 short stay beds, staffed in-house 24/7 by our Pediatric Hospitalist group, a 23. Vincent is part of Indianas largest not-for-profit health system with 22 ministries and over 3000 physicians. You will be provided with a copy of this information to read and sign at your office visit. Peyton Manning Childrens Hospital at Ascension St. Our rates are representative of the usual and customary charges for our area. Acknowledgement & Patient Communication Consent Formĭue to recent changes in healthcare plans, some patients have questions regarding patient and insurance responsibility for services rendered.Authorization for Release of Medical Records Form.If you would like to take the time to complete our forms prior to your initial visit the forms are available in a printer friendly version.Note that if a co-pay is required by your insurance company, it is due at the time of your visit and may be paid in cash, by check or with a credit card.Bring a copy of any important prior records if you are transferring your care from another doctor.At your request, we can also send you our New Patient Information Packet in advance to fill out and bring to your first appointment. Please arrive a few minutes early to fill out paperwork.Bring all current medications in original bottles.If you are not able to complete the forms before your visit, please allow at least 30 minutes for completion in the office before you see the doctor. Please select and print from the options below, fill them out completely and bring them with you to your appointment. For your convenience, you may complete new patient forms in advance.
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