Financial/Forms

Thank you for choosing our practice. We are committed to the success of your medical treatment and care and strive to keep your costs reasonable and manageable.

With offices in Port Royal, Bluffton, and Hampton.

Financial Policies

For your convenience, we accept several forms of payment, including the following:

  • Cash
  • Personal Checks
  • Money Orders
  • Visa
  • MasterCard
  • American Express
  • Discover

We participate in most major insurance plans. Since these contracts frequently change, we may ask you to contact your insurance company to verify our participation in your plan. Our staff will verify your insurance status and may ask for your card(s) at each visit. Some insurance plans have co-payments and this will be collected at the time of service. If insurance verification cannot be established during your visit, full payment will be expected at that time until the matter can be resolved.

Our office manager and/or insurance coordinator can assist you further should you have additional questions.

We currently contract with Medicare, BCBS, TriCare, MailHandlers, Workmans Compensation, and Medicaid just to name a few.

If you are not sure about your coverage, please contact your insurance provider to verify that we are in network with your plan.

If you have an HMO or other managed care plan, you need a referral authorization from your primary care physician. This is also necessary for out-of-state plans. If we have not received an authorization prior to your arrival at the office, your appointment will have to be rescheduled.

If you have commercial insurance, which is also known as indemnity, regular insurance, insurance, and 80%/20%, then payment is your responsibility for all office visits, office procedures, and other charges at the time of the office visit. Our staff will call your insurance company ahead of time to determine deductible and co-insurance.

If the services are covered by your plan, then all applicable co-pays and deductibles are requested at the time of the office visit. If the services are not covered by the plan, then payment in full is requested at the time of visit. Our staff will call your insurance company ahead of time to determine co-pays, deductibles, and non-covered services for you. We will also file an insurance claim on your behalf.

If you have an HMO with which we are not contracted, then payment is required in full for office visits, office procedures, and other charges at the time of the visit. Our staff will provide the necessary information for you to complete and file your claim directly with the insurance company.

If you have a point-of-service plan or out-of-network PPO, then payment that is the patient’s responsibility (deductibles, co-pays, non-covered services) is required at the time of the visit. Our staff will call your insurance company ahead of time to determine out of network benefits, copays, deductibles covered and non-services. We will also file an insurance claim on your behalf.

If you have regular Medicare and have not met your deductible, we ask that it be paid at the time of service. Payment for any service not covered by Medicare is requested at the time of the visit. If you have regular Medicare as primary, and also have secondary insurance or Medigap, then no payment is necessary at the time of visit. If you have regular Medicare as primary, but no secondary insurance, then payment of your 20% co-pay is requested at the time of the visit. Our staff will file the claim on your behalf, as well as any claims to your secondary insurance.

We accept Medicaid only as primary, but not as a secondary insurance. Any co-pay required by your Medicaid option is due at the time of the visit. Out staff will file the claim on your behalf.

If we have verified worker’s compensation claim with your carrier, then no payment is necessary at the time of visit. If we are not able to verify your claim, then payment in full is requested at the time of the visit. Our staff will call your carrier ahead of time to verify the accident date, claim number, primary care physician, employer information, and referral procedures.

If you do not have insurance, then payment in full is required at the time of your visit. Our staff will work with you to settle your account. Please ask to speak with our office manager or insurance coordinator if you need assistance.

A parent or legal guardian must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment of the account, according to the policy outlined on the previous pages. A minor is considered anyone under the age of 18.

Because of the amount of time allotted for scheduled office visits, we do request at least 48 hours notice for cancellation of any appointment. If you are scheduled for an office visit, our staff will attempt to contact you as a friendly reminder one business day before your appointment. Please help us serve you better by keeping scheduled appointments.

Patient Forms

To help expedite your visit with us, please download, print, and complete necessary forms prior to your scheduled appointment. To ensure you are seen quickly and on time, we request that all new patients and those returning after three years complete the New Patient Registration form, New Patient Questionnaire, and HIPAA Statement before your appointment time.

If you are returning for a follow-up visit, please complete the Follow-Up Visit Questionnaire prior to your next visit. If requested by your doctor or our staff, you may also need to complete the Headache Patient Intake Form.

For patients requesting medical records from our office or who need their records sent to us from another medical provider, please complete and submit the Patient Records Release Form.

  • New Patient Registration
  • New Patient Questionnaire
  • HIPAA Statement
  • Follow-Up Visit Questionnaire
  • Headache Patient Intake Form
  • Patient Records Release Form

Financial Policies

For your convenience, we accept several forms of payment, including the following:

  • Cash
  • Personal Checks
  • Money Orders
  • Visa
  • MasterCard
  • American Express
  • Discover

We participate in most major insurance plans. Since these contracts frequently change, we may ask you to contact your insurance company to verify our participation in your plan. Our staff will verify your insurance status and may ask for your card(s) at each visit. Some insurance plans have co-payments and this will be collected at the time of service. If insurance verification cannot be established during your visit, full payment will be expected at that time until the matter can be resolved.

Our office manager and/or insurance coordinator can assist you further should you have additional questions.

We currently contract with Medicare, BCBS, TriCare, MailHandlers, Workmans Compensation, and Medicaid just to name a few.

If you are not sure about your coverage, please contact your insurance provider to verify that we are in network with your plan.

If you have an HMO or other managed care plan, you need a referral authorization from your primary care physician. This is also necessary for out-of-state plans. If we have not received an authorization prior to your arrival at the office, your appointment will have to be rescheduled.

If you have commercial insurance, which is also known as indemnity, regular insurance, insurance, and 80%/20%, then payment is your responsibility for all office visits, office procedures, and other charges at the time of the office visit. Our staff will call your insurance company ahead of time to determine deductible and co-insurance.