When your child sees the provider for a preventative routine medical exam (Well Visit). This is a comprehensive, preventative medical evaluation and management annual exam, including age and gender appropriate screening, labs and/or diagnostic procedures. Most preventative medical visits are exempt from copayments; however, your insurance carrier may or may not cover the screening labs or diagnostic procedures. These are usually carrier specific. Please check your benefits. Additionally, if during this visit the provider is faced with addressing a separate problem requiring additional evaluation, management of a specific medical concern, or having preexisting conditions, then a separate office visit may be billed and could result in you having a copayment due if charged by your insurance company.
If you have any questions regarding this policy, we suggest you check with your insurance carrier to discuss your coverage for these services.
Sincerely, Dr. Smita Parikh Mengers Dr. Wendy R. VanBronkhorst
I certify that I have read and understand the difference between a preventative visit (Well Visit) and a problem-based visit, agree to pay the associated co-pay should my insurance company find it appropriate to bill me for one.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.