PATIENT FORMS

PATIENT INTAKE FORM

ACCEPTED INSURANCE

At Capitol Urogynecology, we accept Medicare assignment.  Typically, Medicare pays 80% of the fee and your secondary will pay the 20% balance unless you have an HMO as your secondary (if that is the case, you are responsible for 20% of the Medicare fee).
We do not accept any commercial insurance.  Payment for services rendered is due at the end of the appointment.  We will provide you with an itemized receipt that you are welcome to file with your insurance company for reimbursement.  It is the patient's responsibility to know the out of network benefits offered by their insurance carrier prior to scheduling an appointment or filing for reimbursement

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