Common use of Laboratory Services Clause in Contracts

Laboratory Services. Your physician may order laboratory services to assist in diagnosing your condition or as preventative care to determine your current health status. Your insurance benefits may not cover all services provided or ordered by the provider. This includes: pap smears, testing for sexually transmitted disease, screening and diagnostic labs, genetic testing and drug screening. In some instances these services may be applied to your annual deductible or not covered. It is the patient’s responsibility to know the coverage, limitations and exclusions of your insurance policy. Returned Checks WHASN’s central billing office accepts checks as payment on an account. In the event a check is returned by the bank for “non- sufficient funds”, “closed account”, “return to maker”, “check voided”, “stop payment” and “un-authorized signature”, a $25.00 fee will be assessed to your account. We may choose to proceed with legal action which will result in additional fees to you or the guarantor of the account. You are responsible for the additional fees. Cancellation / No Show Policy If it is necessary to cancel your scheduled appointment, we request that you notify us at least 48 hours prior to the appointment. A “no-show” is someone who misses an appointment without cancelling it at least 48 hours prior to the scheduled appointment time. A failure to present at the time of a scheduled appointment will be recorded as a “no-show”. You will be charged $25 for “no-show” appointments. FMLA / Disability Forms There is a $25.00 charge for each FMLA/disability form/signature completed by this office. Payment is due at the time the form is submitted. All FMLA/disability forms are completed by the office staff. There is generally a 7-14 day waiting period for the completion of these forms. The physician’s documentation in your medical chart serves as the basis of all FMLA/disability forms and cannot be enhanced by yourself or the office staff. It is important that you understand the difference between FMLA and disability forms. Disability forms can only be completed after the physician has determined the patient has a medical condition that warrants the patient to be off work. Normal symptoms during pregnancy (nausea, vomiting, headaches, swelling, pelvic pain/pressure) do not typically qualify as a medical disability.

Laboratory Services. Your physician may order laboratory services to assist in diagnosing your condition or as preventative care to determine your current health status. Your insurance benefits may not cover all services provided or ordered by the provider. This includes: pap smears, testing for sexually transmitted disease, screening and diagnostic labs, genetic testing and drug screening. In some instances these services may be applied to your annual deductible or not covered. It is the patient’s responsibility to know the coverage, limitations and exclusions of your insurance policy. Returned Checks WHASN’s Our central billing office accepts checks as payment on an account. In the event a check is returned by the bank for “non- sufficient funds”, “closed account”, “return to maker”, “check voided”, “stop payment” and “un-authorized signature”, a $25.00 fee will be assessed to your account. We may choose to proceed with legal action which will result in additional fees to you or the guarantor of the account. You are responsible for the additional fees. Cancellation / No Show Policy If it is necessary to cancel your scheduled appointment, we request that you notify us at least 48 hours prior to the appointment. A “no-show” is someone who misses an appointment without cancelling it at least 48 hours prior to the scheduled appointment time. A failure to present at the time of a scheduled appointment will be recorded as a “no-show”. You will be charged $25 50 for “no-show” appointmentsoffice visits; $100 for ultrasounds and $200 for procedures. FMLA / Disability Forms There is a $25.00 45.00 charge for each FMLA/disability form/signature completed by this office. Payment is due at the time the form is submitted. All FMLA/disability forms are completed by the office staff. There is generally a 7-14 day waiting period for the completion of these forms. The physician’s documentation in your medical chart serves as the basis of all FMLA/disability forms and cannot be enhanced by yourself or the office staff. It is important that you understand the difference between FMLA and disability forms. Disability forms can only be completed after the physician has determined the patient has a medical condition that warrants the patient to be off work. Normal symptoms during pregnancy (nausea, vomiting, headaches, swelling, pelvic pain/pressure) do not typically qualify as a medical disability.