Patient Center

Patient Forms

For your convenience, please print and complete these forms before your appointment. Bring them with you to your appointment.

Complete Patient Packet
Individual Patient Forms

Practice Policies

Insurance Policy

Carroll County Nephrology, PC accepts most insurance providers. As the providers/coverage list would be very long and subject to frequent changes, we ask that for questions and information regarding specific providers and coverage, you call our office at 770-832-0429 and ask to speak with our insurance representative.

Managed Care Insurance Policy

To accommodate the needs and requests of our patients, we participate in numerous managed care insurance programs.

While we are pleased to be able to provide this service for you, it is impossible for us to know all the individual requirements of each of the plans, especially since they change frequently. Each insurance company, plan, and group has different stipulations regarding what services can be provided to you, how often services may be rendered, where those services may be rendered, if and when a referral is needed, etc. Even within the same insurance company, plans differ based upon what type of contract and benefits your employer or group has negotiated.

Providing quality medical care for our patients is our primary focus. As such, we are more than willing to provide that care within your insurance contract guidelines if you let us know prior to service the specific guidelines.

If you do not inform us of any special requirements in your contract and we subsequently order service(s) on your behalf (such as lab work, hospitalization, etc.) that are not covered by your insurance plan, our office, as well as the selected medical facility, we will have no choice but to bill you directly for those charges. Payment for those charges then becomes your responsibility. If services are provided and your coverage is not in effect on that day, the fees submitted and denied by your insurance carrier will become your responsibility.

Our primary focus will be to concentrate on caring for your medical needs. In addition, we will cooperate and help you by submitting all of the information possible to your insurance company, so you can receive all of the benefits to which you are entitled.

Financial Policy

All co-pays are due at the time of visit. This includes the 20% coinsurance allowed by Medicare if you do not have a secondary insurance. If you have deductibles under your plan that applies to our visits, you are responsible for paying this in a timely matter. Please contact our billing department if payment arrangements are required.

Carroll County Nephrology requires a 24 hour notice for all cancellations. If no one is available when you call, please leave a detailed voice message with your name and date/time of appointment. If appropriate notice is not given, there will be a $25.00 charge.

Carroll County Nephrology PC accepts cash, check, money order, VISA and MasterCard as forms of payment. Please be aware there will be a $30.00 charge for non-sufficient funds for returned checks marked with non-sufficient funds. This is an automatic debit done by our bank.

Carroll County Nephrology PC will charge an administrative fee of $15.00 to patients requesting forms (examples: medical records copies, disability, family medical leave,medical equipment forms, etc.), to be completed by staff. The patient is responsible for this fee.

Self-Pay Policy

For patients without medical insurance coverage, we bill at the current Medicare rates. We request that all self-pay patients contact our billing office at 770-832-0429 prior to their scheduled appointment to receive a cost estimate for the office visit.

Payment in full is expected at the time of service We appreciate your attention to this matter.