Updated January 2, 2018
|
|
- Sophie Shepherd
- 5 years ago
- Views:
Transcription
1 Service Charges Updated January 2, 2018 Important Notes:! Service charges and availability are subject to change.! No show and late charges may also apply.! What you pay out-of-pocket is dependent on your health insurance plan benefits. Services with no additional charges:! Up to five (5) individual/couples/nutrition counseling sessions per semester! Group counseling services! Counseling crisis intervention services! Tobacco cessation programs! Health education and prevention programs! Note: No show and late charges may still apply. Please refer to the following tables to see general charges for services within each area. Departments are listed in alphabetical order. Allergy & Asthma Services Allergist Consultation $ $ Injections $12.00 $14.00 Pulmonary Function Test $47.00 Pulmonary Function Exercise $79.00 No Show $5.00 This listing provides a summary of procedures and services provided by CSU Health Network Allergy and Asthma services. Information on charges for additional services is available at (970) Counseling Services Missed Appointment or Late Cancellation Charges Counseling- Missed Appointment $15.00 Counseling Late Cancellation Charge $10.00 Counseling Appointment Charges Counseling Individual/Couples (1-5 sessions per semester) Counseling Individual/Couples (over 5 sessions per semester) $10.00 Group Services Crisis Intervention Services Drugs, Alcohol and You (DAY) Programs DAY Life Safe Program $90.00 DAY BASICS Program $90.00 DAY Taking Steps $ DAY Back on TRAC (for the first month) $ DAY Back on TRAC (each additional month) $ DAY Substance Use Assessment $ Page 1
2 Dental Services Adult Prophylaxis (Class 1) $67.00 Bitewing Radiographs (depending on quantity 2-4) $ $48.00 Composite Resin (tooth-colored filling; based on complexity) $ $ Crown, Gold $ Crown, Porcelain $ Diagnostic Casts $82.00 Examination (problem-focused or comprehensive) $65.00 Extraction (varies due to complexity) $ $ Periodic Oral Exam (patient comes in every six months) $37.00 Dental Records/X-Ray Copies $16.00 This listing provides a summary of selected procedures and services provided by CSU Health Network Dental Services. Information on charges for additional services and dental treatment supplies is available upon request at (970) Immunizations Please note that vaccine prices are variable and prices may need to be adjusted as vaccine costs vary. What you pay out-of-pocket is dependent on your health insurance plan benefits. Injection Fees: An injection fee of $33 for the first vaccine and $17 for each additional vaccine may apply. Injection fee prices will vary depending on insurance coverage Vaccine Name Price Per Dose 2018 Hepatitis B (need 3 doses) $85.00 per dose Hepatitis A (need 2 doses) $95.00 per dose Hepatitis A & B (Twinrix) (need 3 doses) $ per dose HPV 9 (Gardisil TM ) (need 3 doses) $ per dose Influenza (Flu shot) $35.00 (*Injection fee waived) Japanese Encephalitis (special order, must preorder for 2 doses) $ per dose Meningococcal (Menveo TM, Menactra TM ) $ Meningococcal B (Bexsero TM need 2 doses) $ per dose Pneumococcal (Pneumovax 23) $ MMR (need 2 doses) $80 per dose Polio $48.00 per dose Rabies (need 3 doses) $ per dose PPD $11.00 Tdap $50.00 Td $45.00 Typhoid Injectable $ Approximate $88.20 Typhoid Oral (need Rx filled at pharmacy) (price may vary depending on insurance coverage) Varicella $ Yellow Fever $ Yellow Fever Occupational Health $ This listing provides a summary of the most common immunizations provided by CSU Health Network. Information on charges for additional immunizations is available upon request at (970) Page 2
3 Laboratory Services CBC $15.00 Chem Panel, Basic $15.00 Comprehensive Metabolic Panel $19.00 Draw Charge $4.00 HCG Urine $11.00 Lipid Profile $23.00 Liver Panel/Hepatic Function $14.00 Mono Screen $12.00 Nasal Smear (EOS) $7.00 Ova & Parasites $16.00 Throat Culture $9.00 Triglycerides $10.00 TSH $29.00 Urinalysis, Routine $6.00 Urine Culture $14.00 Wet Prep $8.00 This listing provides a summary of the most common tests and charges by CSU Health Network Laboratory Services. Information on charges for additional laboratory tests is available upon request at (970) Massage Therapy Services Massage Therapy (1 hour) $39.00 Massage Therapy (30 minutes $23.00 Medical Services (includes Primary Care, Women & Gender Care & Psychiatry) Annual GYN Exam $ $ Aspiration of abscess/hematoma/bull/cyst $ Audio $41.00 Biopsy of Skin $ Colposcopy $ Colposcopy w/ Biopsy $ Cryocautery of Cervix $ Destruction Lesion $ Diaphragm Fitting $79.00 Ear Irrigation $ $34.00 EKG w/ rhythm strip $22.00 Eye Irrigation $72.00 Excision of Benign Lesion (0.5 cm 2.0 cm) $ $ Excision of Nail Partial/Complete $ Incision and Drainage Abscess, Cyst $ $ IUD Insertion* * $93.00 IUD Removal $ IUD Removal $ (continued next page) Page 3
4 Medical Services - (cont.) IUD Removal $ IV Therapy $75.00 Nebulizer (w/ medication) $24.00 Nexplanon Insertion* * $ Nexplanon Removal $ Office Visit $ $ Subungal Hematoma $64.00 Tympanometry $19.00 Wart Treatment $ Wound Repair, Simple (2.5cm or less) $ $ Wound Repair, Simple (2.6 cm 7.5 cm) $ $ No Show (Medical Services) $ $15.00 No Show (Psychiatry) $20.00 * Separate charges are applicable for the cost of the device CSU Health Network provides a variety of medical services. The listing provides a summary of common procedure and services. Information on charges for additional services is available upon request at (970) Medical Records Medical Records (sent to self, insurance company or legal representative) Immunization Records Summary of Behavioral Health or Psychiatric Services (Behavioral Health and Psychiatric records are released at the discretion of the provider) First 10 pages: $14.00 Pages 11-40: $0.50/page Each additional page: $0.33/page $25.00 Nutrition Consultation for Disordered Eating Nutrition Consultations for Eating Disorders Students may receive up of five (5) individual sessions of nutrition consultation and psychological counseling through Counseling Services at no additional charge each semester. Additional nutrition or counseling appointment are $10/session. Missed Appointments $15.00 Late Cancellations $10.00 CSU Health Network provides nutrition consultation for disordered eating (bulimia, anorexia nervosa, binging and purging, use of laxatives or diet pills). Additional nutrition services are available on campus. Visit for more information. Page 4
5 Optometry Services Comprehensive Eye Exam $90.00 Comprehensive Eye Exam w/ Contacts $ Office Visit $ $ No Show (Optometry) $20.00 This listing provides a summary of the most common services provided by CSU Health Network Optometry Services. Information on charges for additional optometry services is available upon request at (970) Pharmacy Services CSU Health Network operates a full-service pharmacy that is open to the public and can fill most prescriptions. Please contact the CSU Pharmacy at (970) with questions regarding current products and pricing. Physical Therapy Services Cast Application, Short Leg* *$ Cast Application, Elbow Finger* *$ Orthopedic Consultation $ $ PT New/Initial Visit $ PTV, Manual Therapy $39.00 PTV, Mechanical Traction $21.00 PTV, Neuromuscular Reeducation $44.00 PTV, Therapeutic Activities $45.00 PTV, Therapeutic Exercise $42.00 Taping, Ankle* *$34.00 Taping, Hand/Finger* *$38.00 Taping, Patellar* *$37.00 Taping, Shoulder* *$37.00 Ultrasound $17.00 Electrical Stimulation (MANS) $25.00 No Show (Ortho) $21.00 No Show (Physical Therapy Initial Visit) $25.00 No Show (Physical Therapy) $15.00 * Cost of supplies are additional. This listing provides a summary of the most common services provided by CSU Health Network Physical Therapy Services. Information on charges for additional physical therapy services and supplies is available upon request at (970) Page 5
6 Radiology Services * Ankle $77.00 Chest, PA, & Lateral $ $72.00 Elbow $80.00 Finger $81.00 Foot $75.00 Hand $80.00 Leg, Lower $74.00 Shoulder $75.00 Toe $72.00 Wrist $91.00 * These charges include both the cost of taking the X-ray and the cost of Radiological Interpretation by a board-certified Radiologist. CSU Health Network, in partnership with UCHealth, provides comprehensive radiological services for students. This listing provides a summary of the most common x-ray procedures. Information on charges for additional services is available upon request at (970) Tobacco Cessation No Show Charge $15.00 CSU Health Network provides Tobacco Cessation services to fee-paying enrolled students. More information is available upon request at (970) Page 6
OFFICE VISITS Community Fee Range Student Discounted Rate. WOMEN S HEALTH (Additional Fees May Apply) COUNSELING / PSYCHOLOGICAL SERVICES
OFFICE VISITS Primary Care Visit $90.00 - $225.00 $20.00 Special Visit $107.00 - $120.00 $45.00 WOMEN S HEALTH (Additional Fees May Apply) Well Woman Exam w/pap $151.00 - $210.00 $50.00 - $120.00 Well
More information* Collection & Handling Fees billed separately - see Lab Fee Schedule for pricing- pricing subject to change
OFFICE VISITS Community Fee Range Student Discounted Rate Primary Care Visit $120-.00-$277.00 $20.00 Special Visit $120.00 - $295.00 $45.00 WOMEN S HEALTH (Additional Fees May Apply) Well Woman Exam w/pap
More informationStrategic Affiliations
? The Great Unknown Triple Aim SERVICES MENU We treat the whole family ages 12 months and up. Illnesses $ 89- $ 129 Additional fees may apply if further testing is needed for diagnosis. Allergies Bronchitis
More informationConcord Hospital Cost of Care Estimates
Hospital Departments Laboratory Services Basic Metabolic Panel (BMP)(80048) $88 N/A $88 $35 Blood draw (36415) $29 N/A $29 $12 Complete blood cell count (CBC)(85025) $88 N/A $88 $35 Comprehensive Metabolic
More informationIt s good to have options
DPCMH PLANS (Direct Primary Care Medical Home) At the center of Aliera s PrimaCare TM Senior program is the Direct Primary Care Medical Home model of care. We modified this simple, but effective, model
More informationIt s good to have options
DPCMH PLANS (Direct Primary Care Medical Home) When it comes to the health of your loved ones At the center of Aliera s PrimaCare TM program is the Direct Primary Care Medical Home model of care. We modified
More informationLABORATORY PROCEDURES IMAGING/RADIOLOGY PROCEDURES THERAPY GVH EMERGENCY DEPARTMENT PROCECURES
PROCEDURE CHARGES / HOSPITAL may vary depending on circumstances. Prices subject to change. LABORATORY PROCEDURES Basic Metabolic Panel $112.00 80048 Comprehensive Metabolic Panel $140.00 80053 UA Micro
More informationUNIVERSITY OF UTAH INTERNATIONAL TRAVEL CLINIC Phone: Fax: N Medical Dr. Salt Lake City, UT 84132
Welcome to UNIVERSITY OF UTAH INTERNATIONAL TRAVEL CLINIC Phone: 801-801-581-2898 Fax: 801-585-7315 50 N Medical Dr. Salt Lake City, UT 84132 Our goal is to help you have a safe and enjoyable experience
More informationHospital Charge Information List
Hospital Charge Information List To better inform our patients, Norton Healthcare has prepared the following price list of our charges for some of the more common reasons for a hospital visit. They include
More informationSutter Health Plus Effective for Calendar Year 2015
Sutter Health Plus Effective for Calendar Year 2015 CPTs CPT Descriptions 2015 Cost Under Deducible (Single Unit) Doctor's Office Visit for a New Patient (Also Urgent Care) 99201 Low Level Visit $99.00
More informationKaiser Permanente 2013 Sample Fee List
Kaiser Permanente 2013 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges. COLORADO As your partner in health, we want to help you manage your health care
More informationKaiser Permanente 2012 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges.
Kaiser Permanente 2012 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges. NORTHERN CALIFORNIA As your partner in health, we want to help you manage your
More informationKaiser Permanente 2015 Sample Fee List 1
Kaiser Permanente 2015 Sample Fee List 1 SOUTHERN CALIFORNIA Knowing how much you can expect to pay for care and services can give you peace of mind. This Sample Fee List shows you estimated charges for
More information2019 Patient Price Information List
2019 Patient Price Information List In compliance with state law, Genesis Healthcare System is providing this price list containing our charges for room and board, emergency department, operating room,
More informationWorld Bank Group Medical Benefits Plan (MBP) A Guide to Preventive Care Effective 2015
World Bank Group Medical Benefits Plan (MBP) A Guide to Preventive Care Effective The Bank Group s Medical Benefits Plan (MBP), Continuation Medical Benefits Plan (CMBP) and Retiree Medical Benefits Plan
More information301 W. Alder, Missoula, MT or
301 W. Alder, Missoula, MT 59802 406-258-4745 or 406-258-3363 Routine Immunizations are available on a walk-in basis: Mondays, Tuesdays, Thursdays, and Fridays from 9:00am to 4:30pm Wednesdays, 10:00am-4:30pm
More informationYukon Immunization Program Manual ADMENDMENTS & ADDITIONS
2012 August Page 1 Manual ADMENDMENTS & ADDITIONS Number & 11-01 2011 June 09 11-02 2011 October 11 12-01 2012 Feb 9 Topic Additions to Yukon Immunization Program Manual Twinrix, Twinrix Junior, Menamune,
More informationReport of Medical History
Report of Medical History Students are required to have a current Report of Medical History if they plan to live in university housing. These records can be obtained from the high school, college or university
More informationInternational Travel Medical Questionnaire
International Travel Medical Questionnaire Name: of Birth: Gender: M/F Last First Month/Day/Year Circle One Address: Street City, State Zip Daytime Phone: Evening Phone: Primary care physician: Emergency
More informationOur Mission. To promote healthy and safe travel by providing medicines, preventive vaccines and health counseling to a diverse group of travelers
Our Mission To promote healthy and safe travel by providing medicines, preventive vaccines and health counseling to a diverse group of travelers The Travel Clinic utilizes national and international travel
More informationStudent Health Services 881 Commonwealth Ave, West / Student Information (To be completed by the student) Student Name Last First Middle
Medical Clearance The following information must be completed on the medical history form, if any information is missing the form will be considered incomplete and will not be processed. If you have questions,
More informationCLINIC. Frequently Asked Questions
About Target Clinic 1. How is Target Clinic different from a regular urgent care clinic? Target Clinic is a convenience-care clinic. Our medical professionals can diagnose and treat illnesses, minor injuries
More information99202 Office visit new patient, problem expanded $ Smoking and tobacco use cessation counseling visit $37.30
MILBRIDGE MEDICAL CENTER FAMILY PRACTICE 24 SCHOOL ST, MILBRIDGE ME 99202 Office visit new patient, problem expanded $140.90 99406 Smoking and tobacco use cessation counseling visit $37.30 99397 Preventive
More informationIMMUNIZATION & PHYSICAL FORM CELOP
Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617) 353 3575 IMMUNIZATION & PHYSICAL FM CELOP BU Student ID #: Necessary for all students U PLEASE
More informationIMMUNIZATION & PHYSICAL FORM
Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U PLEASE UPLOAD
More information2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest.
2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest. Guidelines may change throughout the year based on new research and recommendations. Get the most up-to-date
More informationPatient Price Information List January 1, 2018
In compliance with state law, Western Reserve Hospital is providing this price list containing our charges for Room and Board, Emergency Department, Operating Room, Physical Therapy, Pain Medicine and
More informationYoung Adults (Ages 18 26)
Young Adults (Ages 18 26) Vaccines help prevent many diseases. Some new vaccines are available today that were not in use just a few years ago. By protecting yourself, you help protect everyone around
More informationAshtead Hospital. Private GP Services. Ashtead Hospital
Ashtead Hospital Private GP Services Ashtead Hospital Private GP appointments at a time to suit you It is our commitment to practice modern medicine with traditional values. At the heart of our service
More information2017 Patient Pricelist
2017 Patient Pricelist Attached are the most frequent charges at St. Elizabeth Healthcare. All patients are charged the same irrespective of one s ability to pay. The patient s responsibility may vary
More informationUnderstanding Your Costs and Coverage
Understanding Your Costs and Coverage Thank you for choosing UW. We know that understanding your healthcare costs can be a challenge we re here to help. Your healthcare costs depend on many factors such
More informationSHENANDOAH UNIVERSITY HEALTH FORM
SHENANDOAH UNIVERSITY HEALTH FORM Welcome to Shenandoah University. This cover letter is to help clarify the immunization and testing requirements for our Health Professions Programs. All students admitted
More information2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest.
2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest. Guidelines may change throughout the year based on new research and recommendations. Get the most up-to-date
More informationInternational School Bangkok Physical Examination Report (New Student)
Physical Examination Report (New Student) A registered Medical Practitioner must complete this form. The examination should be completed no more than 6 months prior to commencement at ISB and submitted
More information2017 Preventive Health Care Guidelines
2017 Preventive Health Care Guidelines NEXT All Adults 4 Women 6 Pregnant Women 8 Children 10 Guidelines may change throughout the year based on new research and recommendations. Get the most up-to-date
More informationPreventive Care Coverage
STAYING WELL Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association Preventive Care Coverage Wondering what preventive care your plan covers? Our
More information2016 Preventive Health Care Guidelines. Free preventive care to help you be your healthiest.
2016 Preventive Health Care Guidelines Free preventive care to help you be your healthiest. We want to help you be your healthiest. That s why we recommend over 30 free preventive care services for kids,
More informationIMMUNIZATION & PHYSICAL FORM
Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U PLEASE UPLOAD
More informationIMMUNIZATION & PHYSICAL FORM
Boston University Student Health Services 881 Commonwealth Ave 1 st floor WEST Boston, MA 02215 Phone: (617)-353-3575 IMMUNIZATION & PHYSICAL FM BU Student ID #: Necessary for all students U Instructions:
More informationInfectious Diseases Consultants of Oklahoma City
Infectious Diseases Consultants of Oklahoma City Travel Clinic Questionnaire Patient Name:. DOB: / /. q first visit q return visit Adress: Phone: Primary Purpose of travel: q Business q Personal q Mission
More informationPatient Price Information List
Patient Price Information List In compliance with state law, Morrow County Hospital is providing this price list containing our charges for room and board, Emergency Department, operating room, physical
More information2018 Preventive Schedule
2018 Preventive Schedule Effective 1/1/2018 PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The
More informationMadison College School of Health Education. Health Forms & Immunization Requirements
Madison College School of Health Education Health Forms & Immunization Requirements It is important that you know your immunization history. You will need your vaccination record to complete your health
More informationPreventive Care Coverage
Preventive Care Coverage Benefits designed to protect your health BridgeSpanHealth.com Review Coverage» To find out if you re eligible for preventive coverage, call the Member Services number on the back
More informationBe Healthy. Be Healthy. Using Your Wellness Benefits. Helping You Stay Healthy. Wellness Benefits
Be Healthy Wellness Benefits Be Healthy Using Your Wellness Benefits Helping You Stay Healthy Health Alliance emphasizes prevention through comprehensive wellness coverage. We support members throughout
More informationLaboratory Testing: Medication Dependent. The Newly Diagnosed Patient. Why Talk about This? Lack of Primary Care
Why Talk about This? Lack of Primary Care Health Care Maintenance in the IBD Patient Sunanda Kane, MD MSPH FACG FACP AGAF Mayo Clinic Rochester Many patients with IBD are young and do not have co-morbid
More informationWELLNESS CENTER Student Health Services (434) FAX (434)
Page 1 WELLNESS CENTER Student Health Services (434) 223-6167 FAX (434) 223-7071 New Student Health Form The staff at Student Health are dedicated to providing you with high-quality health care designed
More informationPrevents future health problems. You receive these services without having any specific symptoms.
PREVENTIVE CARE To help you live the healthiest life possible, we offer free preventive services for most Network Health members. Please refer to your member materials, which you received when you enrolled
More informationSTUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943
Page 1 STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943 NEW STUDENT HEALTH FORM The staff at Student Health are dedicated to providing you with high-quality health care designed specifically
More informationPublic Statement: Medical Policy. Effective Date: 01/01/2012 Revision Date: 03/24/2014 Code(s): Many. Document: ARB0454:04.
ARBenefits Approval: 01/01/2012 Effective Date: 01/01/2012 Revision Date: 03/24/2014 Code(s): Many Medical Policy Title: Immunization Coverage Document: ARB0454:04 Administered by: Public Statement: 1.
More information2018 Preventive Schedule
2018 Preventive Schedule Effective 1/1/2018 PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The
More informationBe Healthy. Be Healthy. Using Your Wellness Benefits. Helping You Stay Healthy. Wellness Benefits
Be Healthy Wellness Benefits Be Healthy Using Your Wellness Benefits Helping You Stay Healthy Health Alliance emphasizes prevention through comprehensive wellness coverage. We support members throughout
More informationGolden Plains Community Hospital
Prices The prices listed below are current for February 1, 2019 but are subject to change. Some prices listed are average prices for select services. If you would like an estimate for a service not listed
More informationEastern Maine Medical Center Patient Price Information Effective October 1, 2017 September 30, 2018
Eastern Maine Medical Center Patient Price Information Effective October 1, 2017 September 30, 2018 To help our patients make informed health care decisions, Eastern Maine Medical Center has provided pricing
More informationHealth Careers and Nursing Immunization and Health Requirement Form
SEE THE ACCOMPANYING HEALTH REQUIREMENT COMPLETION GUIDE FOR STEP BY STEP INSTRUCTIONS = DENOTES ANNUAL REQUIREMENT TITERS ARE REQUIRED FOR BOTH MMR (MEASLES-MUMPS-RUBELLA) AND VARICELLA MMR TITER DATE:
More informationDISCLOSURES TO CONS UMERS:
DISCLOSURES TO CONS UMERS: These discount medical plans are NOT health insurance or a MediCare Prescription Drug Plan. Membership in these programs entitles you to discounts for certain medical services
More informationGolden Plains Community Hospital
Golden Plains Community Hospital Prices The prices listed below are current for January 1, 2019 but are subject to change. Some prices listed are average prices for select services. If you would like an
More informationSTUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410
STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410 P / 336-316-2194 F / 336-316-2184 A completed immunization record is required to be submitted
More informationVassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.
Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York 12604 Please contact us at health@vassar.edu for any questions/concerns. This form must be submitted directly to the Health Service by July
More informationGracePointe Healthcare PLLC
GracePointe Healthcare PLLC Modern medicine the old fashioned way PLEASE PRNT AND COMPLETE N FULL Date Patient's Legal Name: Last First Nickname Sex: Male Female Birthdate: Age: Patient's Social Security
More informationPreventive Health Care Guidelines. Free preventive care to help you be your healthiest.
2016-2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest. Priority Health is committed to improving the health and lives of you and your family. That s why we give
More informationPrior to starting at the University of the Pacific, there are several health clearance requirements that need to be completed.
Academic Year 2018/2019 Dear Dental Student: Please read this packet carefully. It contains critical information for your success as a student. It is our pleasure to welcome you to the University of the
More informationStudent Health Record
LAWRENCE MEMORIAL/REGIS COLLEGE NURSING AND RADIOGRAPHY PROGRAMS Student Health Record All three parts of this record must be complete. Health Records must be uploaded to the Castle Branch website at https://mycb.castlebranch.com
More informationPatient Price Information List
Patient Price Information List In compliance with state law, Wayne HealthCare is providing this price list containing our charges for room and board, emergency department, operating room, delivery, physical
More informationTHIS FORM IS FOR MEDICAL STUDENTS ONLY IMMUNIZATION RECORD
Student Health Requirements Student health forms (physical exam and immunization records) are due in the Office of Clinical Education by March 1st for those students admitted on or before December 31st,
More informationHOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam
Checklist of Immunizations/TB tests/medical History/Physical Exam Note: this checklist must be submitted with the immunization/tb testing forms Please complete ALL of the requirements below and check off
More information2019 Preventive Schedule Effective 1/1/2019
2019 Preventive Schedule Effective 1/1/2019 PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The
More informationDENTAL HMO EMPLOYER SPONSORED or VOLUNTARY
DENTAL HMO EMPLOYER SPONSORED or VOLUNTARY DeltaCare USA Plan Type HMO Plan Name Silver Gold Exam & Diagnostics Office Exam Initial Oral Exam Periodic Oral Exam Teeth Cleaning Bite-Wing X-Ray Oral Surgery
More informationMedical Information Form
Fill in form with a computer Medical Information Form Child s Name: first name, last name Date of Birth: month, day, year Health Insurance information o Insurance group number, policy number, contact information:
More informationImmunization Packet for Incoming Students
Health Occupations Division (707) 256-7600 Immunization Packet for Incoming Students Congratulations on being accepted into a Napa Valley College Health Occupations Program. This packet has been designed
More informationAKE WITH Y KEEP AND T
VACCINATION RECORD Vaccination, the best protection This booklet is an important document. It is the only record of all the vaccines you have received. You will need it all your life, so keep it in a safe
More informationFamily and Travel Vaccinations
Family and Travel Vaccinations We offer the full range of baby, child and family vaccinations. We are able to tailor schedules to your child s needs or international schedule. We have a suggested vaccination
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK
More informationCoverage of Vaccines Medicaid and Child Health Plus Members
Coverage of Vaccines Medicaid and Child Health Plus Members For children between the ages 0-18, routine recommended vaccinations are covered through Vaccines for Children program [VFC]. Fidelis Care will
More informationMAXIMIZE YOUR HEALTH CARE COVERAGE Trinity Health s Preventive Care Benefits
MAXIMIZE YOUR HEALTH CARE COVERAGE Trinity Health s Preventive Care Benefits Important Information Please Keep for Future Reference making the most of my benefits portfolio Chances are you ve heard someone
More informationImmunization Requirements
Please Read Carefully. Health Care Provider: A physician (MD or DO), Nurse Practitioner, Physician s Assistant, or Registered Nurse. English: All immunization forms and laboratory reports must be submitted
More informationMedica Health Plans. Minnesota Fee Schedule Revised 5/1/2016 NEW PATIENT EXAMS: MN Medicaid. Medicare
Medica Health Plans Minnesota Fee Schedule Revised 5/1/2016 NEW PATIENT EXAMS: 99201 Problem focused history and examination --straightforward $23.48 100% of CMS $29.53 99201.25 Problem focused history
More informationArizona Clover Health Choice PPO (040) 2019 Medical Benefits
Arizona 2019 Medical Benefits Effective Date: 1/1/2019 Version 1.0 Part D Deductible For Part D Copay information, see page 26. /year for Part D prescription drugs /year for Part D prescription drugs Out-of-Pocket
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/HSA Plan EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK OUT-OF-NETWORK CATEGORY
More informationIMMUNIZATION AND MEDICAL HISTORY FORM
HEALTH SCIENCES GRADUATE STUDENTS IMMUNIZATION AND MEDICAL HISTORY FORM THIS IS REQUIRED INFORMATION Complete this form and return by November 1 st to: STUDENT HEALTH SERVICES 2040 Campus Box Elon, NC
More informationService Bundle 1 Appendectomy - Outpatient 2 Asthma 3 Back Pain - Lumbar Diskectomy 4 Back Pain - Lumbar Fusion 5 Back Pain - Lumbar Laminectomy 6
1 Appendectomy - Outpatient 2 Asthma 3 Back Pain - Lumbar Diskectomy 4 Back Pain - Lumbar Fusion 5 Back Pain - Lumbar Laminectomy 6 Birth Control - Cut and Tie Tubes 7 Bladder Exam - Cystoscopy 8 Bunion
More informationRoom and Board - Per Day Charges
At Augusta University Health System, we strive to provide the information you need to understand every aspect of your care. In keeping with this promise, AUHS is providing this price list for our services.
More informationRoom and Board Per Day Charges
In compliance with state law, Olean General Hospital is providing this price list containing our room and board, inpatient service, emergency room, operating room, physical therapy and other procedures.
More informationSumma Barberton Hospital Usual and Customary Charges for Selected Procedures Patient Price List
In compliance with state law, Summa Barberton Hospital publishes charges for room and board, emergency department, labor and delivery, operating room, lab, radiology and other procedures. This publication
More informationDENTAL HMO EMPLOYER SPONSORED or VOLUNTARY
DENTAL HMO EMPLOYER SPONSORED or VOLUNTARY DeltaCare USA Plan Type HMO Plan Name Silver Gold Exam & Diagnostics Office Exam Initial Oral Exam Periodic Oral Exam Teeth Cleaning Bite-Wing X-Ray Oral Surgery
More informationStay well with this list of screenings, vaccines and medications that are 100% covered
PREVENTIVE CARE SERVICES Stay well with this list of screenings, vaccines and medications that are 100% covered Table of contents 3 Your preventive care benefits 4 For men 6 For women 8 For pregnant women
More informationStudent Health Information
Student Health Infmation Vassar College This fm must be submitted directly to the Health Service by mail, email, fax by July 1. Please complete all sections. Please do not separate the sections. Incomplete
More informationReport of Health History
Report of Health History MARLBORO COLLEGE TOTAL HEALTH CENTER Phone: 802-258-9335 Name DOB / / Please complete the first five pages of the form below before going to your Health Care Provider Name Birth
More informationLast Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
More information2016 Rochester Regional Health PPO Medical Plan Summary
Out of Annual Deductible Annual Deductible includes co-pays, coinsurance. The amounts are combined across all s. None Single Two-Person EE + Children Family $1,800 $3,600 $5,400 $5,400 Annual Out of Pocket
More informationKeck Graduate Institute
Keck Graduate Institute In order to provide a safe and healthy environment at The Claremont Colleges, all students are required to complete this health record prior to entry. IMPORTANT GENERAL INFORMATION
More informationSKAGIT VALLEY FAMILY YMCA
Central Preschool Registration 2019-2020 Child s First : MI: Last : Address: City: State: Zip Home Phone: ( ) Gender: Birth : Age: Child lives w/ Mother/Guardian: Cell Phone: ( ) Employer: Work Phone:
More informationPreventative and Immunization Brochure
Preventative Immunization Brochure Table Of Contents 2016 Medicare Advantage Preventative Visits Guidelines... 1 Preventative Visits... 3 Common Preventive Services s*... 5 Additional Services Provided
More informationPreventive Services at 100%
September 1, 2014 Update Preventive Care Services Covered Without Cost-sharing Without Copay, Coinsurance or Deductible The Affordable Care Act (ACA) requires non-grandfathered health plans and policies
More informationEMS Education. Immunization/Physical Policy 2016
EMS Education Immunization/Physical Policy 2016 Immunizations: Students are required to have successfully completed immunizations or immunization series, as recommended by the Centers for Disease Control
More informationStudent Health Services
MEDICAL RECDS of birth Home address City State ZIP Home phone number Gender identity: Pronouns: Chosen Name Class status (circle): First year Sophomore Junior Senior Graduate Postbac Premed IN CASE OF
More informationAction Item for 2019 Review of Tool. Maintain (add include oral cavity) Maintain. Archive. Archive. 12 creatinine)
NEWLY DIAGNOSED/ NEW TO CARE PROGRAM SITE: REVIEWER(S): REVIEW DATE: CORE SERVICES Outpatient/Ambulatory Health Services Tool - 2018 (OLD) SECTION 1: CHART REVIEW Review for newly diagnosed HIV patients
More informationOccupation Agency Code Work Location Work Supervisor Duty tel. #
PRIVACY ACT STATEMENT: This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a). This information may be provided to appropriate Government agencies when relevant to civil, criminal
More information