• Patient Registration
  PDF doc to print or complete electronically
• Notice of Privacy Practices

              PDF doc

• Release of Information Authorization from the office of CCCW (to authorize another provider to obtain your records from CCCW)
  PDF doc to print or complete electronically
• Release of Information Authorization to the office of CCCW (to authorize CCCW to obtain your records)
  PDF doc to print or complete electronically

Group Pregnancy

Imagine . . . having two hours to spend with your health care provider at each visit.

Imagine . . . becoming friends with other expectant moms as you meet together for seven months.

Imagine . . . going for your prenatal check-up and beginning your appointment exactly on time.

Imagine . . . learning to take better care of yourself and your family.

Imagine Centering Pregnancy!

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CCCW Policy

• OUTSTANDING BALANCE:  We urge you to keep your account current to avoid any misunderstandings with our office.  All account balances past due over 120 days will be sent to an outside agency for collections.  At that point, the account is out of our hands.  If you need to make special arrangements, it is your responsibility to contact Commonwealth Medical Management (CMMS) before your account is sent to an outside agency.  Accounts sent to an outside agency/Attorney will be assessed 33% to the total balance plus any additional cost, court or legal fees that may occur as a result of your delinquency.  In the event your account is sent to an outside agency, you may be suspended from the practice and no additional appointments will be scheduled until your account has been cleared. If your account is forwarded to an outside agency, you may also run a risk of being discharged from the practice and be required to transfer your care to another provider.

• FINANCIAL POLICIES AND PROCEDURES:  Complete Care Center for Women is dedicated to providing you the most efficient care and service possible. Your understanding of our financial policy is an essential element of your care and service. If you have any questions regarding any aspect of our policy, please feel free to present your question to any member of our staff. Full payment is due at the time of service. If you have insurance, and have signed an “Assignment of Benefits ” statement, we will bill your insurance carrier for you if we are a contracting provider with your plan. We believe that all patients who come to this office deserve the best medical care that can be provided. In order for us to provide you with the highest quality medical care and current technology, we must insure that we are able to meet the expenses necessary to operate this facility. To ensure that these expenses are met, we provide you with this agreement to acquaint you with our financial policy.

• PAYMENT AT TIME OF SERVICE:  As a courtesy, we will bill your insurance for all office visits. Although we file insurance claims as a courtesy to you, you are still responsible for payment of services regardless of the a mount your insurance pays. We ask that you pay any portion not covered by your insurance due to deductible or co-payment on the day of service, unless other wise specified in the policies of Complete Care Center for Women. This includes all office visits, procedures, and injections.

If you are unable to pay your co-pay or co-insurance, you may be asked to reschedule your appointment unless other arrangements have been made with the Office Manager prior to your scheduled appointment. Please remember... Your insurance coverage is a contract between you and your insurance company and not a substitute for payment.

Under special circumstances, payment arrangements can be made. These arrangements are made with the Office Manager prior to you being seen. Our office may set this up for you as a courtesy depending on the circumstance. You will be sent a monthly statement. However, it is your responsibility to know your monthly due date, which will be determined at the time your payment arrangement is contracted. After one missed payment, your arrangement will be voided and the account will be sent to an outside agency for collections.

 

• APPOINTMENT POLICY:  We will work hard to accommodate appointments that fit your schedule and medical needs. We ask that you let us know about cancellations or changes twenty-four hours in advance. Habitual missed appointments are grounds for dismissal from the practice.

Failure to contact the office within 24 hours of your scheduled appointment to either cancel or reschedule, will result in a no show fee of $50 for the missed appointment.

• BILLING PROCEDURE:  Once your claim/s are filled with your insurance company and payment or denial is received, you will receive a statement informing you of the balance you are responsible for paying. If there is a remaining balance due after your insurance carrier pays, you have 30 days to make payment on the invoice. Payment arrangements can be made for special circumstances by contacting Commonwealth Medical Management (CMMS) at (804)740-8000 or the number printed on your statement within 15 days of the receipt of the invoice. It is your responsibility to make contact with CMMS to make special arrangements.

Any accounts past due over 60 days will receive a late fee of $25 and a monthly finance fee of 2% per month on the total balance.

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What to Bring to Your First Visit