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Your time is valuable. So for your convenience, our patient information sheets are available online for you to print and fill out before your appointment. Just bring the completed form with you and this will minimize your wait time in the office. Please arrive at least 20 minutes early for your scheduled appointment time in order to complete/update any information. Please be aware that if you are more than 15 minutes late for your appointment, you may have to reschedule. We cannot always work you back in to the schedule on the same day, due to the busy nature of the practice, and the consideration of our other patients that do arrive on time. Please make sure that EVERY line is completed, and if a question does not apply, then put N/A on blank line next to it. Thank you, The Staff at The OB-GYN Place, P.A  Patient Information Form  Medical History Form  HIPPA - English  HIPPA - Spanish  Medical Records Release Form  Todays Visit - NEW Patients Only  Todays Visit - EXISTING Patients seen more than a month ago  PHARMACY/PRESCRIPTION RENEWAL     Routine prescriptions are filled at your annual visits.     If you need your prescription refilled, have your pharmacy        fax us a request - (972) 772-3834     You will need to have your prescription information        available for the pharmacy     Routine prescription are not considered an emergency and     generally will not be refilled after normal office hours or     on weekends. FINANCIAL POLICY    The OB-GYN Place P. A. participates in most managed care plans. If the name of our physicians appears in your book of providers, the office will accept your plan. Additionally, the office is a fully integrated practice and the physicians do not compete with one another financially. This allows us to put patient care needs first and to work together to provide the best service. The office staff will file your insurance claim and assist you in determining the extent of your benefits. They will also obtain any necessary pre-certifications for surgeries and hospital admissions. Our managed care contracts require us to collect insurance co-payments at the time service is rendered. Payments for services not covered by insurance including deductibles and surgical co-pays are also required at the time of service. For your convenience, our office accepts Visa, MasterCard, Discover, and American Express. Major insurance carriers that we accept include: UnitedHealthCare BlueCross/BlueShield Aetna Cigna Humana Texas TruChoice Pacificare Unicare Medicare FEES FOR OB CARE AND DELIVERY 1. Our fees for Global Obstetrical Care are $3000 for a vaginal delivery of one child, and $3563 for a C-Section. This fee only includes: 13 Antepartum office visits (Regular OB visits before your delivery) Physician’s fee for Delivery One postpartum visit (does not include pap) 2. The following services are NOT included in the Global package, and are payable AT THE TIME OF SERVICE. Please keep in mind that many of these services are routinely performed during a pregnancy in the interests of good prenatal care. First OB Visit Pre-Natal lab fees Any other lab tests (glucose intolerance, cultures, pap, etc) Any visits that do not pertain to the pregnancy (sore throat, yeast infection, urinary tract infection, colposcopy, etc) Sonograms Injections (RhoGam, Progesterone, flu shots, antibiotic injections) NSTs (fetal non-stress test) BPP (bio-physical profile) Any hospital admits before delivery Tubal Ligation C-section assist Postpartum Pap 3. Any services of other physician specialist, i.e. anesthesiologist, neonatologist, will be billed separately by that physician. 4. Hospital services will be billed separately by the hospital and are not included in our fees. 5. All estimated fees for Global Obstetrical Care are due by the first day of your seventh month (Your 28th week). During your first OB visit, the Benefits Coordinator will review the estimated balance due, and discuss your payment schedule. The payment schedule divides the balance due by the number of months between the current month and the seventh month. This payment plan must be followed, although the remainder of the balance may be paid at any time prior to the seventh month. SURGERY POLICY If you require surgery, our surgical coordinator will verify your insurance coverage in advance and give you a call to discuss your coverage. We will also verify any pre-certification requirements. You should also check with your insurance company about whether a second opinion is necessary and the number of hospital days approved with your admission. As a patient receiving services in our care and regardless of your health insurance plan coverage, you are responsible for any unmet deductibles or coinsurance payments. These are to be paid in our office prior to the date of surgery. Payment may be made by cash, credit card, cashier’s check, or CareCredit. We do not accept personal, or two-party checks for surgery payments. CLAIMS & STATEMENTS We will submit a claim directly to your insurance carrier for all procedures. We make our very best effort to work with each insurance carrier to obtain timely payment and reconcile any payment disputes. TEXAS STATE LAW requires insurance carriers to pay claims within 30 days of receipt of claim for electronic format submission, and within 45 days for non-electronic format. Insurance carriers who fail to comply with these state standards are subject to additional requirements and penalties. Many, in fact most, insurance carriers have been very slow in reimbursing physicians for services rendered and are therefore not in compliance with these regulations. The OB-GYN Place has instituted a policy to address unpaid charges that have been submitted to your carrier. However, there is a limit to the services we can provide. When your insurance provider delays or withholds payment for 90 days or longer, both the insurance portion and patient portion will become your responsibility. The statement you receive from us will show the claim, insurance payment (or none), guarantor payment, adjustments and remainder or amount due from you. If, after you have paid this outstanding balance, your insurance carrier follows through with payment, we will certainly credit your account. We strongly suggest you review the statement when you receive it. If your insurance carrier has not paid in 45 days, we recommend that you contact your insurance carrier directly. In many cases you, as the patient, have more influence with your insurance carrier in getting your claims paid. Some insurance carriers send copies of your EOB (explanation of benefits) in the mail. Others allow you to access your EOB’s online. You will want to request a “claim status report”. Keep in mind the following when speaking to your insurance carrier representative: • Identify the date of service for the unpaid portion • Record and retain the date you called your insurance carrier • Record and retain the name of your claim representative • Identify and correct the problem causing the payment delay • Verify that your insurance provider has the appropriate billing information including:         1. Full Name of insured         2. Complete address of insured         3. Guarantors name for the policy         4. Social Security number for the guarantor         5. Correct billing address for you policy         6. Insurance policy number Be sure to ask the claim representative when you can reasonably expect a payment and correction of the problem, and follow-up with the same claim representative if you haven’t received timely issuance of payment.