All Seasons Tooele  obgyn

(435) 843-2576
196 East 2000 North, Suite 104
Tooele, UT 84074

 
 
stansburySprings

All Seasons Tooele Patient Forms

 

We provide all new patient forms online so you can complete them in the convenience of your own home. You may download and print any of the office forms listed below.  Your completed forms can either be brought to the office at the time of your visit, or fax them to us prior to your appointment.

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com

  • Patient Registration Form

  • Financial Policy & Agreement

  • HIPPA Information and Consent

  • General Consent for Treatment

  • Consent for Release of Information

  • Insurance and Billing

  • AETNA

  • Altius Health Plans

  • Beechstreet

  • CIGNA Healthcare

  • Deseret Mutual Benefit Administrators

  • Educators Mutual

  • First Health

  • GEHA

  • Great West

  • Health Utah

  • Humana

  • Intermountain Healthcare/Select Health

  • Molina

  • Multiplan/PHCS

  • NV Medicaid

  • Public Employee Health Plan

  • Tall Tree

  • Tricare Prime

  • Tricare West

  • United Healthcare

  • University of Utah

  • UT BCBS

  • UT Medicaid

  • UT Medicare

  • Wise Provider Network

  • Non-Participating Insurance Companies

    We participate with most insurance carriers.  If we do not participate with your insurance company, we will submit claims for you as a courtesy.  If the insurance company does not pay within 45-days, you will be responsible for payment of all charges.

    Non-Covered Services

    In the event that your health insurance plan determines a service to be “not covered,” you will be responsible for the complete charge.  Should this occur, we will bill you and payment is due upon receipt of that statement.

    Payments

    Co-pays, Deductibles and Co-Insurance are a contract between you and your insurance carrier, and are due at the time of service. Some contracts require more than one co-pay on the same date of service if you have two different types of exams or procedures done. Your co-pay and/or deductible is due at the time of service, unless prior arrangements have been made with our office.

    Prior Authorizations

    If your insurance requires pre-approval or referrals to our practice, it is your responsibility to ensure that the referral has been made.

    Insurance Forms

    We will complete the medical portion of insurance forms for you. Please allow 3-5 business days for completion of disability, compensation, or insurance forms.

    For Questions

    Please speak with our billing staff if you have any questions about your account. We want to work with you to avoid any financial problems and to ensure that your account remains in good standing.  Please contact our billing office if you have any financial questions or concerns about your account at (435) 775-9972.



     

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