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Forms

Our forms are available for you to print out and fill in before coming to our office. This can save you time. We also have forms to facilitate retrieving your medical records. All our forms are produced in Acrobat format PDF. If you need the free reader, click here and it can be downloaded to your computer.

CA STATE DISABILITY

California state law provides for disability income for qualified women beginning 4 weeks before their initial due date, regardless of when they actually deliver.  The diagnosis used for this standard disability is simply “Pregnancy”.  We use other diagnoses for other conditions if a woman must leave work earlier than the 4-week mark.  Disability payments will continue for 6 weeks following a vaginal delivery, and 8 weeks following a cesarean section.

STATE DISABILITY INSTRUCTIONS:

  1. for more information and tutorials if you need.

  2. Disability forms can be filled out either online (the easy way), or you can request the form to be sent to you to be filled out by you then sent to us for completion and we will send the form in for you.

  • The SDI Online process can be started by first registering by clicking
    How To File Link.

  • Once the registration is complete, you may log in and complete your claim by visiting the SDI Online Login page.

  • Complete all of the information that you are allowed to enter, you can “pre-enter” all of this before you are off work to get your claim started, but the website will not allow a future date to be entered so your claim cannot be submitted until the day after your last day of work.

If you require further assistance with the process, please call our main office at 925-935-5356, and ask to speak with the disability coordinator.

WORK SPONSORED DISABILITY FORMS

If your employer requires additional disability forms, these may also be completed by our disability coordinator, along with any doctor’s notes/letters as needed.

PERSONAL FAMILY MEDICAL LEAVE (FMLA) / BABY BONDING

Should you choose to stay home for longer than what is allowed for pregnancy related disability, the state will send you the paperwork if eligible when your SDI benefits are almost completed. All that is required is that you fill out all of the requested information and provide either your baby’s  SS# or a copy of the birth certificate, then mail it in.   You do not need any information from our office and there is nothing for us to do.  They will again continue to pay you for another 6 weeks at 60% on the same debit card.  If you have any questions about this, please contact http://www.edd.ca.gov/

FOR SPOUSE/FAMILY MEMBERS PAPERWORK (FMLA):

If a spouse/family member is taking time off work to take care of you (the “patient” with a true medical need) then YES our office will fill out forms for them. If they are taking time off work for “baby bonding”, then our office will not fill out the forms (no medical need). You or your spouse will need to fill them out and send in. To obtain FMLA forms from the state please visit the same website and request for the FMLA/Baby Bonding forms be mailed to you.

PLEASE KEEP IN MIND WE REQUIRE A $30 PAYMENT WHEN ANY FORM REQUIRING COMPLETION IS DROPPED OFF. THERE WILL BE A 7-10 BUSINESS DAY TURNAROUND FOR THIS SERVICE.  IF YOU WOULD LIKE YOUR PAPER WORK EXPEDITED (24-48 HOUR TURNAROUND), THERE WILL BE A $40 PROCESSING FEE

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SANDRA

DISABILITY FORMS

During your pregnancy, you may need us to fill these forms out. When you bring them in, give them to our disability coordinator, who will fill them out, place a copy in your electronic chart, and send the original to the appropriate disability department (There will be a charge for this service).

ARLENE

PRACTICE MANAGER + BILLING COORDINATOR

She is able to answer questions related to billing and insurance authorizations. Please call her with billing or administrative questions or suggestions that would help our office run more smoothly (friendly, constructive criticism is always welcome).

Billing/Insurance

Billing

We are very pleased to inform you that as a courtesy to our patients we will file claims with your insurance company for all health care services provided during your visit.

Before each visit, we encourage you to contact your insurance company’s Customer service Center to discuss what is covered, what is not covered, and what your co payment or coinsurance is for office visits, laboratory procedures, and mammograms. This will ensure you have an estimate of what your out-of-pocket costs will be for each visit and/or service provided. Please call us if you have any questions about what services may be provided during your visit.

At the time of your appointment, we will collect your co-payment or coinsurance due for services provided. We accept credit cards for payments. We do not accept cash.  Please let our receptionist know when you arrive for your appointment how you would prefer to pay for your services.

Please note that your attending physician may provide a service based on his/her professional judgment that is later deemed a “non-covered benefit” by your insurance. If you receive a “non-covered benefit” notice from your insurance company, please call them for more information. Any account not paid as agreed upon by you and our Business Office will be sent to our collection agency. This action will discharge you from the practice. You will be responsible for collection fees and any associated attorney’s fees. Again, please call us whenever you have any questions or concerns about your account before further actions are necessary.  We will be very flexible to arrange a payment agreement to resolve your account balance, so please contact the office to avoid your account unnecessarily being sent to collections.

We try to promptly refund any overpayment to the appropriate payor (you or your insurance company). Please note that any overpayment on a specific procedure (surgery, etc.) will be applied toward any other outstanding charges on the account before a refund amount is determined. If you believe that an overpayment was made, please call and we will gladly review your account with you.

For further questions, please contact BASS Billing/Insurance Department 925-627-3424

FINANCIAL POLICY

In order to reduce confusion and misunderstanding between our patients and our practice, we have adopted the following financial policy. We are dedicated to providing the best possible care and service to you. We regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE, unless other arrangements have been made in advance by either yourself or your health coverage carrier (medical insurance). 

 

For your convenience, we will accept VISA and MASTERCARD.

YOUR MEDICAL INSURANCE

If you do not bring us sufficient information to bill your insurance (i.e., Name, address, phone numbers of the insurance company, medical group name if relevant, ID and group numbers, date of birth and name of primary insured), then full payment is due at the time of service.

IT IS THE POLICY OF OUR OFFICE TO COLLECT ANY COPAYMENT WHEN YOU ARRIVE FOR YOUR APPOINTMENT. We hold contracts with many insurers and health plans. We will bill those plans with which we have a contract, and will only require you to pay the authorized co-payment at the time of service. If your health plan determines a service to be “not covered”, you will be responsible for payment for the complete charge. Payment is due upon receipt of a statement from our office. If we determine prior to your visit that a service is “not covered”, full payment is due at the time of service.

If you have insurance coverage with a plan with which we do NOT have a contract, we will be happy to prepare and send a claim for you on an unassigned basis. This means that your insurance will most likely send payment directly to you. Due to this, payment is due upon receipt of a statement from our office.

Please Fill out the Financial Policy Form and bring it into our office or Fax it to: 925-935-1070

INSURANCE

I am a provider on most PPO plans in this area and currently have limited availability on certain HMO plans for reasons stated in the following excerpt regarding insurance types. Keep in mind, however, that most if not all PPO plans will cover visits and treatment with “out-of-network” physicians should you not find my name on your insurance physician panel. “Out-of-network” visits are usually associated with different co-pays and deductibles.

Questions About Eligibility

Should you have any questions regarding your ability to be seen in our office, please call us and inquire. Insurance issues are often terribly confusing, and we are almost always able to provide answers to our patients’ questions. Additionally, we are happy to bill your insurance for you for care provided by our office.

Evaluation / Treatment When Not Eligible

If you would still like to see me and I am not on your insurance plan, cash, check, or credit cards are accepted. Affordable payment plans are available as needed.

Explanation of Insurance Types

Perhaps background on the distinction between insurance plans will help you if you are considering changing your current coverage benefits for you and your family.

There are currently two major types of health plans: HMO (Health Maintenance Organizations) and PPO (Preferred Provider Organizations) with its alphabetical cousins, POS (Point of Service) and EPO (Exclusive Provider Organization).

HMO (Health Maintenance Organizations)

This type of coverage places your primary care physician (PCP) as the “gatekeeper,” who must approve referral to specialists. This approval process requires that your PCP completes forms subject to the approval of the HMO. Your PCP is limited to referring to the panel of specialists commonly referred to as in-network specialists. In-network specialists agree to deeply discounted fees in return for these referrals. Your already overworked PCP is often inundated with referral paperwork.

The PCP is also graded by your health plan based on the number of specialty referrals that are made. As a result, additional pressure is placed on your PCP when they must refer a patient. PCPs with an inordinately high rate of referrals may be penalized or even dropped from an insurance plan.

Once at the specialist’s office, authorization hurdles must again be navigated. Your specialist is often handcuffed in treatment options based on decisions made by the HMO management.

The advantage to you, the patient of an HMO, is often lower premiums and lower co-pays, although if you go to a specialist who is out of network, the HMO is not obligated to pay for your care. You also have limited geographic coverage, except in emergency situations.

Due to these deeply discounted fees, specialists must often limit the appointment availability, effectively limiting your access to appropriate care.

PPO (Preferred Provider Organizations) This type of coverage does not employ the PCP gatekeeper approach. Your PCP answers only to you and not an insurance company bureaucratic panel. While you will continue to rely on your PCP for when to see a specialist, your treatment is virtually unimpeded. You will still have affordable co-pays. The insurance premiums might be slightly higher, but consider the advantages noted below.

  • Self-referral to most specialists.

  • Quicker access to top specialists.

  • Reduction of paperwork and authorization hassles.

  • Minimal interference in the physician-patient relationship.

  • Reducing the paperwork reduces our administrative costs so that we can focus on providing you with better health care. This is really about a physician-patient relationship. My goal is to provide you with the very best in health care options. You deserve that.

BASS Medical Group is contracted with many commercial insurance carriers (also known as PPO’s) such as Aetna, Anthem Blue Cross, Blue Shield of CA, Cigna, Healthnet, Tricare, and United Healthcare, just to name a few.

Individual plan types vary by payer and employer group so it’s best to check participation with your carrier before booking an appointment. We would encourage you to select your health care coverage very carefully.  Your human resources department or insurance professional will be best able to discuss your plan specific for you.

 

For further questions, please contact BASS Billing/Insurance Department 925-627-3424

BASS Billing

Our office is a division of BASS Medical Group, which is a group of 12 Walnut Creek area Ob/Gyns who are committed to providing the highest level of care to our patients. Please note that if you plan on transferring to or if you are coming from another BASS physician we ask that you notify our office of your transfer. In addition, because we constitute a single organization, any balance due to another physician within BASS will need to be paid prior to being seen in our office.

If you have any questions about our billing practices, please contact BASS billing department at 925-627-3424, or make online payments through their online portal (located on the bottom of your bill): www.bassmedicalgroup.com/about-us/pay-online/

Thank you for your understanding. We look forward to building long relationships with all of our patients as we continue to provide the best possible Ob/Gyn care in our community.

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