We are pleased that you have scheduled your appointment with our practice and look forward to meeting you. Please complete the paperwork below and bring it with you to your appointment. Please make sure that you arrive at our office at least 20 minutes prior to your appointment to allow us sufficient time to process your paperwork. Otherwise, you may not be seen by the physician in as timely a manner as possible. If you forget to bring your completed forms with you, please arrive at least 30 minutes prior to your appointment. If the completed forms are not received prior to your appointment time, your visit will be delayed or rescheduled. Thus, it is to your benefit to have your information completed prior to your appointment. Patients arriving more than fifteen minutes late to an appointment may be rescheduled. It is also necessary to bring your:
- Driver’s license
- Insurance card
- List of medications currently being taken
- Name and phone number of your pharmacy
A copy of these documents becomes a part of your permanent record. Please also be aware that if your insurance changes at any time prior to your appointment, you must notify us at least 48 hours before your next scheduled appointment with this new information. It can take our staff anywhere from 15 to 45 minutes to verify benefits with your new insurance company and may cause delays. Again, we look forward to meeting you, providing you with the best in healthcare and establishing a long-term relationship. Sincerely, Drs. Sigman, Reyes, Napier, Heintges and Harms
If you have medical insurance, we are eager to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policies. Payment for services not covered by your insurance plan and any out of pocket expenses are due at the time of service. Our office collection policy supersedes any other contract language or statements in managed care contracts or other insurance policies. We accept checks, cash, debit cards, MasterCard, Visa, and Discover. We will be happy to file your insurance if you are a member of one of our managed care plans. We do not file claims on insurance plans with whom we do not participate. Returned checks are subject to an additional collection fee of $25.00. We will gladly answer questions regarding your insurance. You must realize, however, that:
- Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
- We will file your insurance on plans we participate with only if we have the necessary information to verify your benefits.
- Our fees are generally considered to fall within the acceptable range of usual and customary by most companies, and therefore, are covered up to the maximum allowable determined by each carrier.
- Not all services are a covered benefit in your contract. Some insurance companies arbitrarily select certain services they will not cover or may set maximum limits. These amounts are your responsibility.
We must emphasize that as a medical care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. It is understood that temporary financial problems arise; you are encouraged to contact us promptly for assistance in the management of your account. If you have any questions regarding the above information, please do not hesitate to ask.
To Our Managed Care Patients
As a courtesy to our patients, our office attempts to verify your insurance benefits prior to your office visit. Unfortunately, the information we receive from your insurance company is minimal and is not usually sufficient for us to completely process your visit with us. When we contact your insurance carrier, we are informed that your insurance falls under a particular category for a specific HMO, PPO or other managed care product, whether you have met your deductible or if it is applicable to your visit, and what your office copay requirements are. If, for example, your coinsurance is 80/20, that means that you would owe 20% of your office visit or other service rendered (after your deductible is met) and the insurance will pay their 80% of covered charges. You may also have a “copay” for your actual office visit. We are not given specifics of your coverage; for example, what procedures your insurance does/does not cover. It is your responsibility to obtain that information prior to your appointment, since only you have access to your plan booklet and the Human Resources Department of your employer. It is important to have this information because you are responsible for paying all charges associated with your care which the insurance does not cover at the time of service. Knowing what your plan does/does not cover will provide you with the choice as to whether you elect certain procedures to be performed. Also, you are more likely to receive the maximum benefits allowed by your policy if you are aware of what your coverage entails. Be sure to bring your insurance card, as this is necessary to file a claim on behalf of your visit. Please note that if you do not bring your insurance card with you, payment in full is expected at the time of service or you may have to re-schedule for another day. You will also need to bring your driver’s license/photo id and method of payment for your co-insurance/copay. We do not file insurance on indemnity plans. Please feel free to contact our office if you have additional questions prior to your appointment. Thank you for helping us make your visit more enjoyable! New Patient Registration Forms »
Medical Records Requests
If you are requesting that AWH either sends or receives records for you, we will need a signed medical records release form prior to processing. Once completed, the release from can be faxed to us at 972-925-0272. Processing medical records requests will take up to two weeks. Please be sure your form is signed and that all fields are completed and legible. This will help expedite the process. Medical Records Release Form »