To save time on the day of your appointment, please print the form below, fill it out, and bring it with you on the day of your appointment.
Patient Information Form (PDF)
Please note: These documents are in Adobe® PDF format. They require Adobe Reader to be viewed. If you do not have Adobe Reader, you can download it for free by clicking here.
Also bring the following items to your appointment:
- Insurance card(s)
- Photo ID
- List of medications
- Any radiology films not done at Mercer Health or JTDMH
(ex: mammograms, MRIs, CT scans)
- Insurance Co-Payment
- Medical Mutual of Ohio
- United Health Care
- Emerald Health
- Interplan Health
It is our payment policy to collect the appropriate payment due from the patient at the time the service is rendered. This may be your co-payment or "co-pay", deductible and/or co-insurance according to your health insurance company benefit plan. We will ask for this at the time of your visit.
Patient Medical Billing Process
St. Marys Surgical Associates, Inc., as a courtesy to you, will submit a medical bill to your primary health insurance company for processing. It is important to give your updated information to the office staff, since your complete and current information is necessary to submit an accurate claim form to your health insurance company. The remaining claim will be sent to a secondary health insurance company, if provided, after payment is received by the primary health insurance company.
St. Marys Surgical Associates, Inc., will mail you an invoice that contains the cost of your service / procedure within 45-60 days after your service / procedure. The health insurance company payment will be deducted from the bill when the payment is received. You are responsible for any outstanding balance, such as non-covered charges as outlined in your health insurance policy.
Uninsured Payment Policy
Patients who are uninsured must pay half of the surgical procedure charge before the procedure is scheduled. St. Marys Surgical Associates, Inc. will work with the patients and set up a monthly payment schedule for the remaining balance.
For questions about your payment policy, please contact the office.