As a result of our sincere desire to base all medical decisions on what is best for you, the patient, not what is best for the insurance company, we do not contract with any insurance carriers. There is nothing "usual" or "customary" about our clinic. We practice medicine better in every way - we offer more convenience, we spend more time with our patients, we do not perform services our patients do not need, and we charge less than 50% of the total cost of a traditional office visit. We save you more in insurance premiums and taxes than you could ever spend with us.
1. All charges must be paid at the time of service and our treatment fees are the same for all patients, regardless of insurance coverage, or lack thereof, as required by law.
2. The contract with your insurance company to pay for a portion of your medical care is between you and your insurance company. By eliminating costs associated with billing, coding, referrals, authorizations, payment delays, EOB reviews, claim denials, re-submissions, collection risks, and other managed care costs, we can provide patients a fair price for services without the administrative hassles and bureaucracy.
3. For your benefit, we will provide you with our fees and billing codes, upon request, before any services are performed. We recommend you contact your insurance carrier to verify your benefits so you will have a basic understanding of how your insurance will reimburse you for services provided by our office. Unfortunately, insurance carriers are not always willing to provide their allowable fees or disclose which billing codes they will cover. If this is the case, you may want to contact the SC Department of Insurance - http://www.doi.sc.gov.
4. You will be given a completed claim form with all the codes necessary for you to file a claim with your insurance carrier. We recommend you contact your insurance carrier, or search their website, to learn how to file your claim.
5. Due to rising administrative costs and the numerous requests we receive, our office does not fill out “forms” from insurance companies. A copy of the patient’s medical records will be forwarded to the insurance company when a signed authorization to release medical records is received. Their medical review professionals can extract the information required from
6. Please Note: We do not charge interest, therefore, we are unable to offer in-house financing or payment plans. If you are unable to pay for your services in full with cash or money order, you may put the balance on your credit card and make monthly payments to your credit card Dr. Wingo has chosen to “Opt Out” of Medicare. All patients who are on Medicare, or are eligible for Medicare, must sign the federally mandated “Private Contract” in order to receive services at our clinic. All services must be paid at the time of service and neither Dr. Wingo nor the patient may file a claim to Medicare for reimbursement. We are not accepting any Medicaid patients. We will only accept “Private Pay” patients. We will not file any claims to Medicaid for reimbursement of your medical services now or at any We are not contracted with insurance of any kind. Again, we only accept “Private Pay” patients. We will not file claims to your insurance company for reimbursement of your medical services now or at any time in the future.
10. Champus/Tricare: We are not an active Champus/Tricare/Tricare for Life provider. We will NOT accept Champus/Tricare/Tricare for Life insurance, we will NOT file any claims to Champus/Tricare/Tricare for Life and we will NOT accept the Champus/Tricare/Tricare for Life fee schedule for reimbursement of our services.
11. All Patients (please answer all three questions below):
[ ] Yes [ ] No My current symptoms are related to an accident/injury.
[ ] Yes [ ] No I am currently being represented by an attorney and/or I am
[ ] Yes [ ] No I may seek an attorney/workers compensation benefits in regards currently under worker compensation care. to this accident/injury.
ALL charges for attorney cases, workers compensation cases, accident and/or injury cases must be paid in full, in advance, unless an agreement between Dr. Wingo and your attorney has been worked out ahead of time. We will not file any claims for insurance benefits/reimbursement and we will not provide any discounts/write-offs for insurance or workers compensation plans. Our charges are already less than 50% of a traditional office visit. By signing this document, you are agreeing to pay for our services in full and forego any insurance benefits/discounts.
I have read, understand and agree to the terms and conditions listed above.
Name of Patient or Parent if Patient is a Minor
Signature of Patient or Parent if Patient is a Minor Date