School & Camp Forms
To ensure the safety of all our student & adult patients, we require a recent scheduled office visit with a physician or a nursing visit during our regular office hours regarding the completing of any form (i.e. school, camp, work or FMLA). Current information is critical regarding the treatment of life threatening conditions. So, parents/guardians and patients needing these forms completed, please schedule your visit.
Please hand your forms to the front desk at the time of your visit.
The increased complexity of the multiple forms that exist now require our staff 10 to14 days to complete.
Lastly, please read our letter from our physician staff.
Thank you Click Here: FORM – POLICY CHANGE LETTER
Patients Under 18 Years Old
Patients under 18 must be accompanied by a parent or legal guardian. If an adult other than a parent is going to bring the patient please have the parent complete an AQI – Allowed Qualified Individual Form to comply with HIPAA Privacy rules.
Because your physician must review a prescription refill, the lab asks that you give them 24 hours notice before the refill is needed. Your pharmacy name and phone number is information the lab needs to complete the refill quickly.
We accept most major insurance coverages…. ie. BCBS, United Health Care, Cigna, Aetna PPO, Humana, First Health, Medicare….
Remember, we are facilitators for your contract with your insurance company. If you have questions regarding the adjudication of your claim please call your insurance company…
Check with your carrier to verify that Diane L Ozog, MDSC is part of your plan.
Insurance Cards / Co-Payments / Referrals
We require that you present your current insurance card at each office visit or new patient appointment.
This will help us keep your insurance information current on our software system. Thanks…
Patients are required by their insurance companies to pay their co-payment at the time of their office visit. All patients should make necessary arrangements prior to their appointment to pay their copay on the day of the appointment. If your insurance requires a referral or co-payment please have them ready at time of service
HMO Insurances must have an ELMCARE Referral
The practice IPA requires this referral for HMOs. Patients must have this referral at time of service or select self pay.
As of Tuesday, June 15, 2010, the offices of Diane L. Ozog, MDSC will no longer accept Medicaid insurance plans for existing patients and will not accept new patients on Medicaid.
If you do not have other insurance coverage you will be considered Self Pay and be responsible for Payment in Full at the time servies are rendered.
Change of Address, Phone Number or Name
Please notify the front desk if there is a change of your address, phone number, name or insurance coverage