Forms & Policies

Forms

Instructions for Completing Forms

If you want your medical records to be sent to our office from another office, please print the release of records form from the list below, complete it, and mail it to the office which currently has your medical records.

Please select the appropriate form from the list below:

• Authorization for Medical Records
  • FROM Arbor ObGyn
  • TO Arbor ObGyn
• Preconception Form
• Family Medical Leave Act (FMLA) Certification Form

Privacy Policies

Download a printable version of our Privacy Practices

To Our Patients:
Declining insurance reimbursements as well as increasing paperwork required by insurance companies has caused an increase in our staff and physician time and resources. We have found it necessary to impose the fees discussed below. These fees will not be billed to your insurance carrier and will be your responsibility. We are happy to discuss any questions you may have regarding these financial policies.

We are pleased to participate in your health care and look forward to establishing a lasting relationship as your health care provider. These policies and procedures will establish the expectations you will receive from the WHA providers and also what we expect from you as our patient.

1. APPOINTMENTS: Please arrive 15 minutes prior to your appointment time. Failure to submit completed demographic information forms or this Financial Policy form may subject you to reschedule your appointment.
2. MISSED APPOINTMENT: You (not your insurance company) will be charged for a missed appointment unless cancelled 24 hours in advance.
3. CO-PAYMENTS, DEDUCTIBLES, AND FEES: Co-payment, insurance deductibles and fees for service, not covered by your insurance policy, are typically collected at the time a service is rendered. We accept Cash, Visa and MasterCard. For Elective Procedures Personal checks must be presented no less than seven (7) days prior to the procedure, allowing enough time for the check to clear the bank, or we will accept Cashiers checks. There is a returned check fee.
4. INSURANCE: Patients must complete and sign information/insurance forms prior to seeing the physician or other provider. A current insurance card must be presented at each visit, if not you will be responsible for payment in full at the time of visit. You will receive a refund (within 30 days) upon payment by your insurance company. If WHA is not contracted with your insurance carrier, you are responsible for payment in full at the time of your visit. If your insurance company deems your visit a non-covered service, you will be responsible for payment in full.
5. MAIL ORDER MEDICATIONS: You are responsible for obtaining any necessary insurance prior authorization requirements for your current medications. Please provide the appropriate completed forms at the time of your visit for us to accommodate your needs.
6. AFTER HOURS CONSULTATIONS/ Rx REFILLS: For non-emergent issues or prescriptions we ask that you please call during regular office hours, otherwise a charge may be billed to you.
7. LAB BILLS: If you have questions about your bill, please contact the lab vendor indicated on your lab bill.
8. PAST DUE ACCOUNTS: Payment is due when services are rendered. If we file your insurance claim and they (insurance company) satisfy their responsibility but there is a remaining balance that is your responsibility, you will receive two bills from WHA. If you have not paid in full or arranged and honored a payment plan within the two (2) months, we will refer your account to a collection agency or our attorney. They in turn will report your past due status to a Credit Reporting Agency. Any fees incurred by WHA for Attorney or Court costs will be your responsibility.
9. VISITS: Please be aware that most insurance companies cover one (1) preventive physical visit per plan year. Additional visits will qualify as problem visits and billed as such. It is your responsibility to verify your benefits and financial responsibility before your appointment.
10. COMPLETION OF FORMS: A fee will be charged as patient responsibility for completion of forms and must be paid prior to the release of the form, including the following but not limited to:

Disability, FMLA, and Leave of Absence, Also Letters regarding flying and or airline tickets, coverage of Birth Control Pills, to employers and Merck Medco Rx forms.

We have implemented a new, convenient payment policy using Credit Card on File, effective in our office in April 2016.  As you are aware, the current state of healthcare in our market has resulted in significant changes in insurance policies, co‐pays, deductibles and premiums.  Unfortunately, a great deal of the financial burden now falls on the patient as a result.  There are insurance plans that require deductibles and copayments in amounts unknown to you, or to us, at the time of your visit.  You will be asked for a credit card at the time you check out, and this information will be held securely.  The amount that we will charge to the credit card on file will be the financial responsibility that the insurance company requires you to pay.

Q&A – Credit Card on File

What are the benefits to me?

Patients who have a credit card will no longer have to worry about statements and mailing in payments.  You can also use it to pay for future visits without having to bring your card.  Having a credit card on file will make check‐in and check‐out easier, faster and more efficient for patients.

How does this work?

During your visit, we will ask you to sign a “Credit on File Agreement”.  When our office receives remittance advice/information from your insurance company (typically 2‐4 weeks), any remaining portion of charges will be charged to your credit card.  We will notify you by email FOUR TO FIVE DAYS BEFORE the charge is due to take place, and you may call our office if this presents a problem/hardship for you.  A receipt will be emailed to you after the payment has been processed.  If the payment is declined, we will request updated credit card information or an alternative form of payment.

What if I do not have a credit card?

It has been our policy that payment is due at time of service.  We are encouraging patients to keep their Health Savings Account (HSA) or Flexible Spending Account (FSA) credit cards on file.  If you do not have either of these types of cards, then you can use a debit or other credit card.  We accept Visa, MasterCard and Discover.   

How can I be assured that my credit card information will remain safe?

Under HIPAA, we are under strict state and federal rules and guidelines to protect patient privacy and the credit card is considered protected health information.  Elavon, our credit card processing vendor (as well as a leader in the credit card industry and an affiliate of U.S. Bank), will store your information on a secure and encrypted site, which will enable us to run bank card transactions through our computer system.  None of our employees will have access to your bank card information.  No credit card information will be stored in athenaNet or at our practice.

I have never had to do this at any other doctor’s office.

This may be different from what you have always been used to, but it is becoming common practice in most health care facilities with the changes that have come about in the insurance industry as a whole.  Many practices now require a credit card on file, and payment at the time of service.  This policy is being instituted in order to simplify and enhance your patient experience.  This change will lower the practice’s administrative expenses in order to allow us to focus more on providing the exceptional patient care that you have become used to at Arbor ObGyn.