Thank you for selecting Jasper OB GYN as your healthcare provider. Our entire staff is committed to providing our patients with the highest quality of care. Your clear understanding of our financial policy is important to our professional relationship. Please feel free to ask any questions you may have about our fees, financial policy or your responsibility.

Test Result Notification

Patients are notified of results of tests ordered by Jasper OBGYN and instructed to contact the office if they have not been informed of results within 2-3 weeks.  Exceptions to this policy might include normal results for pap smears or other labs, and normal results of screening/routine mammograms where facilities will notify patients according to their facility policy.

Registration and Insurance Requirements

We require complete, accurate and up-to-date information on your registration form in order to bill your insurance company. New and established patients must supply a current copy of their insurance card. This allows us to assist you in collecting the benefits from your insurance company to which you are entitled. We will ask you to update your registration form annually, and ask that you contact us when changes occur (address, insurance coverage, phone number, name, etc.).

Medical Insurance

Medical insurance is a contract between you and your insurance company. Our office is not a party to that contract. Not all services provided to you may be considered covered by your insurance company. We encourage you to become familiar with your insurance plan and to verify coverage for recommended services, tests, laboratory studies and referrals to other doctors. This office cannot be responsible for out-of-pocket expenses incurred from utilizing an out-of-network provider, facility, or for undergoing non-covered tests or procedures. We do understand that insurance rules and regulations can be confusing. We can provide you with limited assistance to help guide you as much as we are able.

Co-Pays

All co-pays must be paid at the time of service.

Referrals

It is your responsibility (the patient) to get proper referral information prior to your appointment.

Self-Pay Patients

If you do not have medical insurance you need to be prepared to pay a minimum $150 towards your initial visit. Likewise, any associated surgery will require an agreed upon prepayment as specified by Jasper OB/GYN with the balance being billed to you afterward. We will accept monthly payments, but the payment must be received at least every 30 days to avoid finance charges. The remaining balance must be paid in full within 180 days from the date of service.

Surgery and Pre-Authorization

We will contact your insurance company to obtain pre-authorization prior to surgery. Obtaining pre-authorization does not mean that your surgery will be covered and you should be aware that insurance companies do not guarantee any payments or benefits until after the surgery is completed and a claim form is submitted. After we have contacted your insurance company, we will contact you to explain your benefits and collect applicable co-pays and deductibles prior to your surgery.

OB Prepayment Plan

The office staff will meet with you following your initial new OB visit to set up a monthly OB Prepayment Plan to discuss the fees associated with your pregnancy. The global fee for obstetric care includes your routine prenatal office visits, uncomplicated delivery, and postpartum visit. This global charge will be filed with your insurance shortly after delivery.

Tests, including pap smears, blood work, ultrasounds, NSTs, and injections provided during your pregnancy and at your postpartum visits are not included in the fees mentioned above. Hospital visits and acute visits outside your delivery stay are also billed separately. These charges will be filed with your insurance at the time they are performed. Payment is due on your account for these charges throughout your pregnancy. Your prepayment will be applied to the above mentioned charges.  If there is not adequate credit in your account, you will receive a statement for additional payment.  You are responsible for any charges not covered by your insurance company.

A prepayment amount each month is required to be applied toward your final charges. After your baby is born and the insurance claim has been processed, you may have a balance on your account. In that event, you will be billed the remaining balance. If an overpayment has occurred, you will receive a refund.

Missed Appointments

We appreciate your help and the courtesy of a call if you are unable to keep your scheduled appointment. Please notify our office at least twenty-four hours prior to the appointment.  Multiple missed appointments without notification could lead to possible dismissal from the practice.

Disability, FMLA, and Other Forms

We realize that special forms are sometimes necessary to provide documentation of medical conditions. We are happy to complete those forms. The form will be completed after payment of $20.00 is collected for the initial form plus $10.00 for each additional form with a maximum of $50.00 per surgery or pregnancy. Please allow 7-14 business days for completion of forms.

Medical Records

Medical Records can only be released upon the patient’s completion of an “Authorization to Release Medical Records” form. Only the patient can sign the release form; friends, and family may not sign for the patient. There is no fee if records are being released to another medical provider.

Statements and Past Due Actions

You will receive a statement if there is an outstanding balance. The billing statement will itemize your services as well as any payment, deductibles, or co-insurance amounts applied by your insurance carrier. If you do not understand your statement or have questions regarding your balance, please contact our billing office at 812-848-4738. In the event your balance becomes past due, the account will be considered delinquent and finance charges will apply. Delinquent accounts are subject to further collection action, including placement with our collection agency/attorney and possible termination from our practice.

We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems with our practice manager so that we can assist you in the management of your account.

Your Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate explaining the expected cost of your medical care. This is part of the No Surprises Act, a federal law that helps protect patients from unexpected medical bills.

What Is a Good Faith Estimate?

A Good Faith Estimate gives you an outline of the expected charges for items and services you may receive. It is not a bill. It is simply an estimate to help you plan for your care.

You can request an estimate before you schedule or at any time during your care with us.

Who Can Request One?

You may request a Good Faith Estimate if you:

• Do not have insurance
• Are not using insurance for your visit
• Want to understand the cost of your care ahead of time

This applies to all OB/GYN services, including:

• Annual well‑woman exams
• Prenatal care and ultrasounds
• Lab work
• Office procedures
• Gynecologic visits and follow‑ups 

Your Rights

You have the right to:

• Receive a written Good Faith Estimate for non‑emergency services
• Ask for an estimate before scheduling
• Dispute a bill if it is $400 or more above your Good Faith Estimate

If Your Bill Is Higher Than Expected

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the charge. You may start a dispute resolution process with the U.S. Department of Health & Human Services.

How to Request a Good Faith Estimate

To request an estimate, please contact our office by emailing billing@jasperobgyn.co,, messaging billing via the portal or calling billing at 812-481-2709. We are happy to help you understand the cost of your care.

Learn More

For more information about your rights under the No Surprises Act, visit: https://www.cms.gov/nosurprises.

Surprise Billing Protections Notice

Notice of Patient Protections Against Surprise Medical Bills

Federal law protects you from certain unexpected medical bills for emergency care and certain out-of-network services. Your cost sharing will be based on in-network rates in these situations. You also have the right to a one-page explanation of these protections before services are provided.

If you believe you received a bill that violates these protections, you may contact Centers for Medicare & Medicaid Services or visit: www.cms.gov/nosurprises or call 1-800-985-3059.