Procedure Billing Form

PLEASE NOTE THAT WHEN HAVING A PROCEDURE PERFORMED THERE ARE TWO SEPARATE CHARGES:

1. ONE CHARGE IS THE PHYSICIAN’S FEE
2. ONE CHARGE IS THE FACILITY FEE WHERE THE PROCEDURE IS PERFORMED

IF YOUR INSURANCE REQUIRES PRIOR AUTHORIZATION PLEASE MAKE SURE THE PROCEDURE HAS BEEN APPROVED BEFORE THE DATE OF YOUR PROCEDURE. THERE IS A LIST OF INSURANCES AT THE FRONT DESK INDICATING WHICH INSURANCES WE ARE CONTRACTED WITH AND WHICH NEED PRIOR AUTHORIZATION.

3. IF A BIOPSY OR POLYPECTOMY WAS PERFORMED YOU WILL RECEIVE A SEPARATE BILL FROM THE PATHOLOGY LABORATORY; THEIR PHONE NUMBER FOR BILLING RELATED QUESTIONS IS (888) 581-1201.

4. IF YOUR COLONOSCOPY HAS BEEN SCHEDULED FOR SCREENING AND YOU HAVE NO SYMPTOMS WITH YOUR BOWELS, AND YOUR DOCTOR FINDS A POLYP OR TISSUE THAT HAS TO BE REMOVED DURING THE PROCEDURE, THIS COLONOSCOPY IS NO LONGER CONSIDERED A SCREENING PROCEDURE, IT IS CONSIDERED A SURGICAL OR DIAGNOSTIC PROCEDURE AND YOUR INSURANCE BENEFITS MAY CHANGE.

Symptoms include: change in bowel habits, diarrhea, constipation, diverticulosis, bleeding, anemia, History of polyps etc.

5. PLEASE READ AND SIGN ALL FORMS PRIOR TO YOUR PROCEDURE. IF YOU HAVE ANY QUESTIONS PLEASE CALL (360) 447-5642.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application