Category: Patient Resources
Privia Patient Forms
Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
Helpful information for our Pregnant patients
The following list of articles and documents are a great reference for our pregnant patients. A hard copy of the articles and documents can be printed by downloading the pdf file within.
- Approved Medications for Obstetric Patients
- Labor Warnings
- Contraception 101
Help and information are just a click away.
Here you will find information about the following:
FINANCIAL and other OFFICE POLICIES
Please be assured that everyone in this practice is dedicated to providing the highest quality medical care to all of our patients, in an atmosphere of caring, trust and mutual respect.
Your understanding of your own financial responsibility is essential.
Our practice policy requires that prior to receiving any services in this office, all patients review and sign the practice financial policy.
In order to become a “provider” of medical services through your health plan, the physicians are required to enter into a contract with an insurance company. Many such contracts stipulate that the physicians will not provide or charge for “unnecessary medical services,” as determined by the insurance companies. Experience has shown that some “health plans” have very different ideas than members, such as yourself, with respect to what is or is not “medically necessary”.
This asserts your conviction that the described services rendered are appropriate and “necessary” as far as you are concerned, irrespective of the determination of your insurance company.
In the more recent years, it has become increasingly difficult to collect the fees rightfully due to the provider for services rendered, in good faith, to their patients. Therefore, we have found it necessary to secure an explicit financial policy for this practice. Oftentimes we find that patients come to the office without payment for the services they are about to receive. We thus ask that you please not present to the office without a form of payment (cash or credit card) to meet your obligations to your insurance provider and to your healthcare provider.
Thank you in advance for taking the time to review this policy. We appreciate your understanding of our need to have a financial policy in place.
Please feel free to discuss any concerns or questions you may have with anyone in our billing staff or our practice manager. We would welcome the opportunity to assist you in your understanding the complexities of health insurance today. These policies have been established to protect the rights of our patients and the physicians who provide care.
Things to bring with you to your visit
- Health Insurance Card – please keep our office updated with any changes in your insurance information.
- Driver’s License or other form of government issued I.D.
- Method of payment – cash or credit card, we no longer accept checks.
- Name of the diagnostic laboratory your insurance requires you use.
Assignment of Benefits
- Personalized Women’s Healthcare will only bill contracted insurance plans as a courtesy to our patients, if the patient has provided the required insurance information in a timely manner and has signed a current financial policy and Assignment of Benefits form.
Billing and Insurance Questions
- We encourage you to call our office during normal business hours with any billing and insurance questions you may have relative to claims from medical care provided by our physicians. Please ask to speak to the billing team or Practice Manager.
- If at any time during your care, your insurance benefits are considered to be COBRA, we must be notified immediately. You must provide proof of current coverage. You will be responsible for payment in full if your insurance company cannot verify coverage for the dates of treatment or you lapse in paying your premiums and your coverage is terminated.
Co-pay, co-insurance and deductible
- Payment is due at the time services are rendered (co-pay, coinsurance and deductible). Patients are expected to pay their estimated portion of the office visit bill at the time of their visit. Patients have an obligation under their contract with their insurance to pay their portion of healthcare expenses as dictated in their “Summary Plan Document” provided to every patient who has health insurance.
- Co-pay: We are obligated to collect the co-pay at the time of your visit, even if you are sick. We are required to do so by your insurance plan. The co-payment amount is determined by your individual insurance policy. If you receive two different types of services on the same day, you will be asked to pay two co-pay amounts if required by your insurance plan.
- Co-insurance: This is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible and before you have met your out of pocket maximum before insurance pays all medical fees at 100%. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%; the 20% portion is due at time of service.
- Deductible: Some insurance plans require that patients pay a predetermined dollar amount prior to services being paid by the insurance.
- At no time will co-pays, coinsurances, or deductibles be waived.
Collections – Referral for Outside collections
- In the event that a balance becomes past due, the account will be considered delinquent.
- Accounts are considered delinquent if no payment is received within 15 business days after third statements have been sent to patients.
- Delinquent accounts may be subject to further collection action, including placement with a collection agency. Accounts that are placed with a collection agency now become the responsibility of the collection agency. In addition, all accounts placed with the collection agency will also be forwarded to three major credit bureaus which will affect your credit report. The patient is responsible for the balance, in addition to any late payment penalties, interest, and legal fees incurred during the collection of funds.
- Patient accounts that have been placed with the collection agency may receive notification that they have been discharged from the practice.
Disability, FMLA, Physicals, and other non-healthcare related forms
- We realize that special forms are sometimes necessary to provide documentation of medical conditions. Completing forms is time consuming and falls outside of the contractual relationship between you and your insurance company.
- We will be happy to complete the form(s) for you. Each form must be accompanied with a filing fee of $30.00 prior to completion. E.g., 2 sets of forms – one from employer and one from disability insurance = $60 etc.
- Please allow 15 business days for completion.
- 48 hours notice is required to verify insurance benefits. Failure to notify the office with insurance changes or presenting without an insurance card may result in the need to reschedule your appointment.
Methods of payments
- We accept cash and credit cards only. We no longer accept checks.
OTHER OFFICE POLICIES
Appointment Reminder Calls/Text/E-mail
- As a courtesy to our patients, appointment reminder emails, calls, and texts are sent 2 days and 1 day before your scheduled appointment through our automated electronic medical records system.
Appointment Scheduling and re-scheduling
- Please call the office to schedule or re-schedule your appointment at a time that meets your needs.
Appointments by phone
- If you need to discuss a healthcare issue or abnormal test results, you will be asked to schedule an appointment to see your physician.
- As our office email is not encrypted in a manner that meets the HIPAA/HITECH Act encryption requirements in order to protect your personal information. We are therefore unable to offer any communication by email that contains any protected health information. Appointment reminders ONLY may be generated using your email on file and your email will be used to send you your link to establish your confidential portal to allow you access to your health information.
Emergency Contact Information:
- This information is required by our office to be kept on file for all patients for use in the event of any patient related medical emergency.
- For patients who are suffering financial hardship and are suggesting they are unable to settle their outstanding balances, you will be required to prove such hardship and provide documentation per OIG (Office of Inspector General) guidelines and assessment made in relation to the current HHS poverty guidelines before a financial arrangement can be established. Please discuss this with the practice manager.
Guarantor and Primary Insured Information
- Personalized Women’s Healthcare requires that the patient’s primary insured (individual who is the primary insured e.g. through employer etc.), and guarantor’s (person who is responsible for paying bills) information is maintained on file as the guarantor is responsible for any payment that the insurance company deems is the patient responsibility.
- Guarantor Information includes, name, DOB, SSN, address, contact telephone numbers, and employer.
- There are federal and state privacy and security regulations that our office is required to implement and comply with in order to make every attempt to protect your personal health information and any related individual identifiers.
- Under these same regulations there are regulations regarding patient rights.
- Please review this office’s Notice of Privacy Practices and sign the Acknowledgement of Receipt of this information (separate form).
- Should you at any time have any concerns about your privacy or have any questions regarding our compliance with these regulations, please ask to speak to our Privacy and Compliance Officer.
Hospital Admission related bills
- Our fees do not include these services or services rendered by the hospital or other attending physicians during any hospital treatment or surgery. E.g. Hospital Fees, Assistant at surgery, Anesthesiologist, Imaging, and Lab tests done while in hospital etc.
Insurance Card and Photo I.D.
- In compliance with this office’s contracts with your health insurance plans and Federal Regulations, personal identification information, health insurance card and demographics must be confirmed at each visit. Verifying this information at each visit also serves to protect our patients from the risk of medical identity theft.
- Your CURRENT health insurance card and U.S. Government issued photo identification must be presented at each visit. We do ask that you verify and/or update your demographic information at each visit.
- In the event that you do not have your health insurance card and U.S. Government issued photo identification with you, you may be asked to re-schedule to a time at which you will be able to have this information with you for a visit.
- Insurance is a contract between you and your insurance company. Your doctor is contracted with most local insurance plans. It is your responsibility to make sure your doctor is a contracted provider with your insurance. Although we may estimate what your insurance may pay, it is the insurance company that makes the final determination of your eligibility.
- It is every patient’s responsibility to be aware of their benefits under their insurance plan and their financial obligations to the physician for services rendered i.e. copays, coinsurance, and deductible.
- Please ensure that you notify the office with any changes to your health insurance.
- Any insurance information provided to our office that is past the timely filing deadline (period of time in days in which a physician must submit a claim to the insurance after the date the services to a patient were provided) will result in a claim being denied and you will then be responsible for paying for that claim/services rendered.
- If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a cash pay patient and will be provided documentation to assist you in filing your claim
- If you have a secondary insurance you would like your claim to be sent to, please ensure you provide the office with the information and have your insurance card with you.
- Our office verifies your insurance benefits prior to each visit. For your ESTIMATED anticipated out of pocket expenses please call the office the day before your visit. The insurance company however, always states this disclaimer ‘verification of benefits is not a guarantee of payment”.
- If you contact your insurance and they state your visit is “covered”, please ask them what your out of pocket costs for the visit will be. We are not able to accept a verbal communication that your insurance has stated you should not pay anything at the time of your visit.
- Our office verifies your estimated out of pocket expenses through the insurance websites and at times by calling them, the information provided to you is based on that verification process.
- You agree to pay any portion of the charges not covered by your insurance.
- If your insurance requires a referral and/or pre-certification, it is your responsibility to make sure this has been done prior to the date of your visit.
Laboratory, Radiology and other diagnostic services bills
- This office is NOT able to verify your diagnostic lab or radiology benefits. Please check with your insurance company to verify what your schedule of benefits allows for any laboratory, x-ray, or other diagnostic studies (bone densitometry, mammogram etc.) that may be ordered by the doctor during your visit. These services will be billed separately by the laboratory or physician that performs these tests and are not covered by the payments that you make at this office.
- Any insurance claims or problems associated with the laboratory must be directed to the insurance department of that laboratory and not our office.
- If your insurance requires a specific lab be used you MUST inform the office (front desk, medical assistant and you physician) of this to ensure your labs are sent to the correct lab.
Medicaid as secondary insurance
- We do not accept patients with Primary commercial insurance and Medicaid as secondary insurance or Medicare as primary and Medicaid as secondary insurance. If you add Medicaid as a secondary insurance after beginning care under a commercial plan (e.g. BCBS, Cigna etc.), you will be asked to transfer care.
- Please make certain that you have a full understanding of your Medicare benefits and your financial responsibility if your services are not covered by Medicare.
Medical records, charges for copies of
- You will be charged for copies of medical records as per Texas Medical Board chapter 165 guidelines. These charges cover the administrative costs of copying such records. Currently these costs are $25 for the first twenty pages and $.50 per page for every copy thereafter. If an affidavit is requested, certifying that the information is a true and correct copy of the records, a reasonable fee of up to $15 may be charged for executing the affidavit. A physician may charge separate fees for medical and billing records requested. The fee may not include costs associated with searching for and retrieving the requested information. A reasonable fee shall include only the cost of: copying, including the labor and cost of supplies for copying; postage, when the individual has requested the copy or summary be mailed; and preparing a summary of the records when appropriate.
- Minor Patients: For all services rendered to minor patients, we will look to the accompanying adult or custodial parent or guardian for payment.
- Consent to treat a minor will be required from the parent, custodial parent, or legal guardian, unless otherwise indicated by Texas Law.
- Parents of minors are required to remain in the office waiting room until the minor’s visit is completed.
- If you request services that are not covered by your health plan, you will be responsible for payment in full for those services. Payment is due at time the services are rendered.
On Call/After Hours:
- For life threatening emergencies – call 911 or go to the nearest emergency room – DO NOT call the office.
- Please call our office at 972-473-2020 for your urgent after hours OBGYN needs. You will be directed to our 24/7 answering service who will then contact the physician on call.
- Our physicians share after-hour calls with another group of physicians.
Outstanding balances/ Collections
- Prior to providing additional services to you, we require payment in full of all total outstanding balances, unless you are on a payment plan that has not lapsed.
Out of Network
- Full payment is due at time of service.
- Appropriate claim documentation will be provided to the patient for filing with their insurance company.
- Payment is due at the time services are rendered (co-pay, coinsurance and deductible). Patients are expected to pay their portion of the office visit bill at the time of their visit.
- The patient or legal representative is ultimately responsible for all charges for any services rendered.
- Your insurance coverage is an agreement between you and your insurance company.
- “Non-covered” means that a service will not be paid under your insurance contract. If non-covered services are provided, you will be expected to pay for these services at the time they are provided, or at the time you/ or our office receives a statement or EOB (Explanation of Benefits) from your insurance provider denying payment.
- Appeal procedures are generally available, and we will be happy to assist your appeal attempts, however we will not change any ICD-10 codes in order for your claim to be paid.
- Our office will not under any circumstances falsify or change a diagnosis or symptom in order to convince an insurer to “pay” for care that is not covered, nor do we delete or change the content in the record that may prevent services from being considered covered.
- If you are unsure whether your plan covers a specific service, it is ultimately your responsibility to contact your insurance company to determine and review your schedule of benefits to ascertain that the service is covered and medically necessary. If the service is subject to a deductible, you can clearly be informed of the extent of your financial responsibility.
- At the time we receive your explanation of benefits from your insurance company, if there is a portion of the claim determined as your responsibility, a statement will be sent for payment immediately.
Prescriptions and Refills
- Our office uses electronic prescribing and we ask that you provide us with your pharmacy information: pharmacy name, address, and Zip Code, as well as a telephone number.
- Your physician will prescribe medications as indicated during your visit. To assist your provider in their efforts to prescribe within the formulary determined by your health insurance company, please have a copy of this available or have a list that is specific to your medical needs.
- For any new prescriptions for new health issues, you will need to schedule an appointment to be seen by your provider for appropriate examination, diagnosis, and medical care. If you choose not to come into the office for care and are self-diagnosing, we ask that you use over the counter medications.
- You will be asked to provide a list of drugs that are on your insurance plans approved list to assist the physicians in prescribing medications that are covered by your insurance plan.
- Professional courtesy will not be offered in any form to any patient or patient’s family.
- Refunds are issued to the appropriate party. Patient refunds will not be processed until all active or past due charges are paid in full and there are no further scheduled appointments.
- Refunds may take 60 days to process.
- We realize that patients still use checks to pay for statements they receive in the mail.
- A fee of $35.00 for checks returned to us for insufficient funds will be charged to your account. Future services will require payment by cash, money order, or credit card for your payment obligations.
- If there are any additional bank fees related to your NSF charge, these will be billed to you to cover the expense to our office incurred by your NSF check.
- NSF checks that are not resolved will be forwarded to the Collin County, Justice of Peace, Texas. Any court costs and legal fees incurred will be borne by the person who wrote the NSF check.
- Your secondary insurance carrier will automatically be billed, if you have provided our office with the information, and we are in network with your plan.
Self-Pay – no insurance
- We offer a very reasonable self-pay fee for patients who have no health insurance coverage in any form. Prior to your visit, you will be provided an estimate of the visit cost and will be required to pay in full at time of check in on the day of your appointment. In the event your provider carries out additional procedures/tests, you will be required to pay for these at the time of check out.
- You will be asked to sign a waiver stating that you have no health insurance coverage and will not be filing with any health insurance carrier.
Social Security Numbers
- Personalized Women’s Healthcare requires that the patient’s SSN is held on file. There are times when information other than your Insurance Member ID number or DOB is used to verify insurance benefits, schedule surgeries etc.
- There are other times that it is necessary to have a SSN on file and that is for collections processing and skip tracing efforts in attempts to collect bad debt.
Statements – monthly
- If you have a balance due on your account, we will send you a monthly statement.
Surgery and Obstetrical Fees – estimates/financial contracts
- You will receive an estimate of the fees for these services, based on the physician’s contracted allowable fee with your insurance, your deductible, co-insurance, and at what percentage your insurance company covers for such services.
- At your initial obstetrical visit you will pay your portion of the visit. You will also receive financial counseling and enter into a pre-payment arrangement with the office.
- The completion of the prepayment is to be paid by the sixth month of pregnancy.
- These estimates are subject to change based on changes in our contracts with your insurance company and/or your insurance changes.
- Obstetrical patients with no insurance coverage are required to pay for their first obstetrical appointment in full and at their second appointment will be required to pay for the entire remainder of estimated obstetrical package. Obstetrical fees for uninsured patients (self-pay) are based on a normal uncomplicated pregnancy. In the event a pregnancy is or becomes high risk, additional fees may be assessed.
- Surgical prepayments (deductible/coinsurance) are due at pre-op appointment prior to the scheduled surgery
Well women/annual visit and Problem/sick visit on the same day
- Some insurance companies will cover well-woman/preventive/annual visits and some will not.
- It is your responsibility to know what healthcare benefits your insurance covers, prior to your visit.
- If you need to discuss any health problems that require evaluation and management (gynecological problem, surgery, etc.), this must be documented separately to your well woman visit and appropriately billed for.
- Your insurance company will not pay for additional problems that are addressed during the well-woman/preventive/annual exam. You will need to make a separate appointment to discuss these problems with your physician.
- Please do not ask our staff to change coding for the purpose of getting your insurance to make payment on services rendered.
- We do not accept any workers compensation or car injury patients or claims.
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Please bring a photo ID and current insurance card to all appointments.