215 E. MANSION STREET, SUITE 3D
MARSHALL, MI 49068

269.781.1183 | 269.781.9248 (fax)

269.789.9298 (After hours emergency)
reception1@mansionstobgyn.com

3600 CAPITAL AVE SW, SUITE 205
BATTLE CREEK, MI 49015

269.719.8046 | 269.719.8049 (fax)

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Forms for First Visit Payment/Insurance Privacy Policy

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Payment &
Insurance Information

 

 

FINANCIAL POLICY

Click for a downloadable copy of our Financial Policy.

Thank you for choosing Mansion Street Women’s Health, P.L.L.C. (MSWH) as your health care provider. We are committed to providing you with exceptional, quality healthcare. We would like you to understand your financial commitment for all services rendered in our office. The following is a statement of our Financial Policy that we ask that you read in its entirety and sign in that you agree. For your convenience MSWH accepts the following methods of payment: Cash, Check, Money Order, Visa, Mastercard, Discover and American Express.

Insurance Claims (Participating)

We have contracts with many insurance companies and will bill them as a courtesy service to you. As the patient of services rendered, you are responsible if your insurance company declines to make payment for any reason. All co-pays are due at the time of your appointment. Below is a partial list of insurance companies with which we are participating providers. If your insurance company is not listed here, please ask the front desk if we are currently a participating provider with your insurance.

Aetna
Blue Cross Traditional & PPO
Cofinity
Healthscope Benefits
Medicaid
Medicare
Meridian Health Plan
Priority Health
United Healthcare
United Healthcare Community Plan

You should know that your insurance policy is a contract between you and your insurance company. Please be aware that it is your responsibility as a patient to know which services (for example: tests, labs, etc.) are covered benefits of your plan. Also please note that some of the services we provide may be non-covered services under your own insurance plan and are not payable by your insurance policy. You will be financially responsible for these services. Secondary insurances will be billed as a courtesy to our patients. Deductibles, co-insurances and non-covered services are due upon receipt of your first patient statement.

Deductibles

If your insurance company has applied our charges for services rendered towards your deductible, then it is deemed your responsibility to make payment to our office. Insurance claims and deductibles are typically paid on a “first come first served/ processed” basis by the insurance company and are not always paid in “Date of Service” order. Deductibles are due upon receipt of your first patient statement.

Non-Participating Insurance Claims

For patients with an insurance plan that we are non-participating with, we will bill your insurance as a courtesy with the understanding that whatever charges come back as not being paid for are your responsibility as the patient.

Minor Patients

Parents or legal guardians of patients who are minors (under the age of 18) are responsible for full payment as described herein.

Records Fee

Copies of your medical records are available to you and are subject to the per page guidelines set fourth by the State of Michigan Department of Community Health. Please inquire with the receptionist for further information.

FMLA Forms

A $10.00 fee will be assessed for each form needing to be filled out and payment in full is required before this paperwork will be released.

Obstetrical Care Patients

Those patients who will be receiving obstetrical care with our office will be presented with additional information regarding your charges and payment options.

No-Show Fees

A no-show / late cancellation fee of $25.00 will automatically be assessed to any patient who does not cancel their appointment at least 24 hours in advance or neglects to show up. Three no-shows are considered non-compliance with scheduled appointments and may result in your dismissal from the practice. In addition, please note that if you show up for an appointment 15 minutes or more LATE , it is office policy that you will be rescheduled. Since many appointments are scheduled and booked months in advance, please be on-time as it may be extremely difficult to be rescheduled timely. Thank you!

*Please note that due to the nature of our practice, our doctors are sometimes called to surgery and/or labor & delivery. If you are here for an appointment and your provider is not in the office, we will advise you at that time. We thank you in advance for your patience in the event this situation arises!

Returned Checks

A fee of $40.00 will be charged to your account for all returned checks to this office for any reason (insufficient funds, stop payment, account closed, etc). This fee is assessed in addition to the amount of the original payment. We will not send the check through the bank more than one (1) time. If subsequent checks are returned to us, we will no longer be able to accept a personal check from you or any immediate family members. Other methods of payment for your account must be utilized at that time.

Non-Compliance

If for any reason you choose not to comply with the MSWH Financial Policy as outlined herein, your account will be reviewed and could result in being forwarded to our collection agency. Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or patient’s responsible party fully understands that MSWH will disclose all relevant personal and account information necessary to collect payment for services rendered. A collection fee of $50 shall be charged to your account if it is forwarded to our collection agency. Additional costs, such as court costs, attorney fees, and any interest charged will be the responsibility of said patient or signed representative acting on their behalf. Any patient sent to collections may also result in being dismissed from the practice.

By signing below, I acknowledge that I have fully read, understand and completely agree to the above financial policy as set forth by Mansion Street Women’s Health, P.L.L.C. This document may be scanned into an electronic format and such printed copy of the electronic record shall be deemed an original.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. We look forward to providing you with exceptional care throughout your visits with MSWH!

Easy Online Bill Pay

Conveniently pay your patient statement online via credit card or ACH of your checking / savings account. If you do not currently have a Code ID and Access Number, please send us an email with your name and telephone number and request your personal access to e-statements.