Appoinment

Patient Form

Like any licensed healthcare service provider, we are required to obtain specific information regarding our patients and their unique circumstances to ensure the highest level of quality care and service. Please complete any of the applicable forms listed below as directed by our staff so we can help you get the most from your experience with us.


CLICK BELOW TO SELECT A FORM


 Consent for Care
 Colonoscopy Consent Form
 EGD Consent Form
 Good Faith Estimate
 Medical Records Release
 No Surprises Act
 OGGI HIPAA Notice of Privacy Practices
 Preparation Information

POLICIES & GUIDELINES


We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, as we do not routinely overbook the schedule for our providers when you fail to meet your appointment it leaves a hole in the schedule we cannot fill with a patient on a waiting list who urgently needs to see the provider.

If an office appointment is not cancelled or rescheduled 2 business days in advanced a $25.00 rescheduling fee will be charged which must be paid before we can re-schedule your visit.

If you fail to provide notice that you will need to cancel or reschedule a procedure 2 business days in advance a $100.00 rescheduling fee will be charged which must be paid before we can again schedule you.

These fees are your personal responsibility and are not billed or paid by your insurance company. Once you fail to meet an appointment without proper notice we are unable to provide priority re-scheduling. Any combination of 3 missed appointments within a 12 month period, or “within a row”, in the office or for a scheduled procedure, will result in dismissal from the practice and you will need to seek care from another physician not associated with Plexus Gastro, Inc.

Plexus Gastro, Inc. takes confidentiality and security of all information seriously. Therefore, we restrict access to areas where patient information is maintained and access to private health information (PHI) is granted only to physicians and staff who need access to perform their duties. In addition, we have internal procedures that are designed to protect your PHI from unauthorized disclosures.

Thank you for choosing Plexus Gastro, Inc. as your healthcare provider. We are committed to providing you with the best possible medical care. A clear understanding of our financial policy is important to our professional relationship and understanding your bill is considered part of your overall treatment. To keep your cost of healthcare to an absolute minimum, we have adopted the following policies.

Fees are standardized and based on the complexity of your visit or procedure. Payment of co-payments and any outstanding balance is required at the time of service. We accept Personal Checks, Money Orders, Credit and Debit Card (Visa, Mastercard, and Discover). While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility. For us to file a claim, you must present a current copy of your insurance card at each visit and communicate any changes in your personal contact information.

Your insurance coverage is a contract between you, and the insurance company; we are not a party to that contract. Before your visit, please contact your insurance company to verify the physician and the facility that you are scheduled with participates with your plan and that the services that you intend to receive are covered.

If you need to cancel an appointment, please call at least two business days in advance, so we can accommodate other patients needed to be seen. Cancellations in less than 48 hours or no shows may be subject to a rescheduling fee of $25.00 per office visit and $100.00 per procedure. Cancellation charges are not covered or paid by any insurance company, and therefore, charges will be billed directly to the patient. All cancellation fee(s) must be paid in full prior to scheduling future appointments. Dismissal from the practice may be the result of excessive cancellations.

Accounts that are not paid in a reasonable amount of time may be sent to an external collections agency and reported to the credit bureaus. This may result in dismissal from the practice.

Disability, FMLA, Life Insurance and other forms often require review and completion of detailed medical history by our clinicians. Please allow 5-7 days for completion of these forms. There is a $25.00 fee for this service, payable in advance.

If you request a copy of your medical records sent to yourself or another physician, these copies are billed on a per page basis, payable in advance, in accordance with HIPAA and Ohio state law. The per page fee schedule is available upon request. If a collaborating physician (primary care or specialist) requests portions of your chart to assist in your care, there is no charge.

Non-Sufficient Funds (NSF) checks are subject to a $30.00 fee (in addition to fees from your bank).

You have the right to receive a Good Faith Estimate explaining how much your health care will cost. To request an estimate, contact our billing department at 313-315-1422, or email service@plexusgastro.com