PLEASE BRING THIS FORM WITH YOU TO YOUR APPOINTMENT by MikeCallan

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									               CRESCENT WOMENS MEDICAL GROUP
            YOUR MIRENA OR PARAGARD IUD BENEFITS
Please be aware it is YOUR RESPONSIBILITY to contact your insurance carrier to
find out if you have birth control benefits and if either of the products listed are covered
under you’re health and/or pharmacy plan benefits. If this is a pharmacy benefit, you
will need to make sure we can order these through Thera-com for you. This can not
come from your regular pharmacy. You will need to then contact our office so we can
place this order on your behalf. Please have them inform you if you have a
DEDUCTIBLE or a COINSURANCE that would apply to this benefit. You will need to
ask if BOTH the insertion and removal are covered. The removal is a separate procedure
from the insertion.

The codes for these products are:

Mirena code    - J7302    Our Fee - $800.00
 CPT code      - V25.02 Encounter for Contraceptive Management

Paragard code - J7300 Our Fee - $725.00
 CPT code - V25.02 Encounter for Contraceptive Management

Insertion code - 58300 Our Fee - $248.00
  CPT code - V25.42 Intrauterine Contraceptive Device

Removal code - 58301   Our Fee - $200.00
 CPT code - V25.42 Intrauterine Contraceptive Device

Of course it will be our pleasure to file your claim to your insurance company. You will
be expected to PAY ANY BALANCES IN FULL with the arrival of your first
statement. Since we are no longer offering payment plans, we are offering financing
through CareCredit for fees over $300.00. Please feel free to contact our billing office
should you have any further questions.

PLEASE BRING THIS FORM WITH YOU TO
YOUR APPOINTMENT TO AVOID THE NEED
OF POSSIBLE RESCHEDULING OF YOUR
APPOINTMENT.
Your Deductible is $_____________ Your Coinsurance is ________%
Is This a Pharmacy Benefit & WILL it Apply to your Deductible & Coins ____________
Do you need prior authorization______? If yes, you will need to contact the office
prior to insertion.

Insurance Respresentative Name, Reference # and Date you called:
_____________________________________________________________

Signature__________________           Date___________________

Witness__________________________                  Date________________________
(Crescent Womens Representative)

								
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