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DISCLAIMER - WELL WOMAN VISIT: I understand that this visit is for preventative maintenance and that no additional problems will be addressed during this visit. If other issues are discussed, I may be charged for the additional medical decision making, labs, prescriptions, etc. If I am having issues, I will schedule a "problem visit."

I acknowledge that I have been informed about and am aware of the Privacy Practices of this office.

Our Doctors run a PRO-LIFE practice; we do not prescribe birth control, tie tubes, or insert IUD's or other devices. We promote fertility awareness and natural family planning. If this is the type of practice you are looking for, we will be happy to schedule an appointment for you.

Payment is required for all services at the time they are rendered. Acadiana OB/GYN, LLC accepts payment in the form of cash, checks, and credit card.

• If a check is returned to the office due to insufficient funds, the original check amount plus a $25.00 return check fee must be received within 30 days from the date the check was returned to avoid further late fees and/or collection action.
• After a balance has reached 45 days past due, a late fee will be assessed. After 90 days past due, your account will be turned over to an outside collection agency for further action. The patient will be responsible for any charges incurred in such action.
• Please help us better serve you and our other patients by keeping all scheduled appointments. If you must change an appointment, please do so as soon as possible, at least 24 hours before your scheduled appointment.
• You will incur a NO SHOW fee if you fail to attend more than 3 of your scheduled appointments without a 24 hour notice. This fee will need to be paid before you can be rescheduled.

PATIENTS WITH PRIVATE INSURANCE

Acadiana OB/GYN, LLC is pleased to participate in a number of different insurance plans. While we are pleased to be able to participate in these plans, it is impossible for our office staff to be aware of each plan's specific requirements. Your plan may have limitations on the frequency of services performed or where service may be performed. Some plans may require a referral from your primary care physician as well. It is the patient's responsibility to inform Acadiana OB/GYN, LLC of specific limitations set forth by their insurance plan(s). If Acadiana OB/GYN, LLC is to order services that are considered non-covered by a patient's insurance carrier, payment for these services becomes the financial responsibility of the patient. Due to the overwhelming number of insurance plans, it is impossible for our office staff to guarantee coverage by any individual plan. It is your responsibility to verify that we are a member of your network before presenting to our office for treatment. It is in your best interest to verify this information directly by calling the customer service number on the back on your insurance card. If we participate with a commercial insurance plan under which you are covered, we will bill the carrier for all charges for services rendered. We will bill both your primary and secondary insurance plans for contracted plans. You will be responsible at the time of service for payment of your annual deductible, co-pays, and any non-covered charges. In the event that we are not aware of a charge that is not covered by your plan, you will be billed for the balance after we obtain a denial from your insurance carrier. For those patients who have chosen a medical insurance plan that we do not have a contractual relationship with, we will require payment in full at the time of service. You will be responsible for the charges for your treatment with your insurance company and we will give you a fee bill that contains all the necessary codes and information that you can file with your insurance company for reimbursement. It is your responsibility to verify that you have insurance coverage for any services rendered to you by Acadiana OB/GYN, LLC.

Please sign below stating that you have been informed of this office policy.

Office Appointments: Our office requires patients to pay a $25.00 fee for any cancellations or rescheduling made less than 24 hours notice.

Surgery: If the rescheduling date request is made less than 1 week notice, we are unable to offer this time slot to other patients in need of care. Therefore, you will be charged a $200.00 fee each time surgery is rescheduled.

Please note that insurance providers do not cover late cancellation or rescheduling fees, so this balance is the patient's responsibility before you can be rescheduled.

We understand that emergencies and unexpected conflicts do arise. Reasons such as new pregnancy or family emergency would exempt patient from this rescheduling fee.

This policy is to ensure fairness for other patients that were not allowed to have their surgery at that time due to the spot being taken up on the schedule. This is not merely about lost OR time for the surgeon, but also about justice/fairness to other patients who are having to wait unnecessarily. However, we must respectfully enforce this policy to ensure all patients have timely access to our care.

Please sign below stating that you have been informed of this office policy.

Unlike other types of services, prenatal care is billed globally and will be billed at the end of your pregnancy, after delivery. Prenatal care includes your office visit and delivery charges.

During your pregnancy, physicians may order additional studies, such as ultrasound and non-stress testes. These services will be billed to your insurance at the time of the service and are not included in the global prenatal care fee. You will be responsible for co-pays and any additional fees for these services, which will be determined by your contract with your insurance.

In addition, please be aware of the cost of delivery. Some insurance companies require the patient to pay part of the delivery charge as a coinsurance and/or deductible. The coinsurance deductible is considered part of the total reimbursement to the doctor. We will arrange a monthly payment plan to pre-collect your deductible which you will be required to pay prior to delivery.

It is your responsibility to inform our office of any changes in your insurance during your pregnancy. If your insurance coverage changes during your pregnancy, it is imperative that you inform our office as soon as possible. We need to obtain a maternity pre-certification to assure your delivery will be covered by the new insurance. You will be responsible for all unpaid balances if you fail to provide the office with a change in your insurance and you deliver without providing our office with proper notification.

If these financial obligations are not met by the specified date, you will be instructed to reschedule appointments until your payments are made current and up to date.

Your signature below signifies that you understand our financial policy and agree to the terms of your responsibility regarding charges incurred at this office.

I authorize the release of any medical information necessary to process any claim(s) filed with my insurance company(s). I hereby authorize an assignment of benefits directly to Damon T. Cudihy, M.D. or John H Voltz, M.D. of all benefits that are payable under each insurance plan. I agree to pay whatever insurance does not pay as is necessary to pay my bill in full.

Insurers and managed care companies occasionally review medical charts to insure compliance with company procedures. I understand that my chart may be selected for such review and that the confidentiality of the information in my chart will be preserved and I hereby consent to such review and release this physician and any such insurer or managed care company for liability for any reasonable review of my chart.

I understand that because I agree to pay for my medical care without the benefit of health insurance, I will comply with the arrangements that are made between myself and Dr. Cudihy’s/Dr. Voltz's financial policy. I understand that these arrangements have been made to best suit my financial situation. In the event that I later find it necessary to apply for financial assistance from the State of Louisiana (Medicaid), I understand that I may not be able to use it to pay for any balance or future charges that I may incur while under the care of Dr. Cudihy/Dr. Voltz.

In the event that my insurance policy is changed, canceled, or my condition is considered pre-existing, I will comply with the arrangements that are made between myself and Dr. Cudihy’s/Dr. Voltz's financial policy. I understand that these arrangements will be (have been) made to best suit my financial situation. In the event that I later find it necessary to apply for financial assistance from the State of Louisiana (Medicaid), I understand that I may not be able to use it to pay for any balance or future charges that I may incur while under the care of Dr. Cudihy/Dr. Voltz.