Insurance and Fees Checklist

Cathryn Harbor, MD

Rockbridge Traditional Medicine

7 Estill Street, Lexington VA – 24450

(540) 463-2882

bridgemed@rockbridge.net

Talking about money is difficult. Our current healthcare system is not structured to pay for the time and effort that resolving chronic health problems requires. Confirm that you understand the costs of working with me, including the costs that are not covered by insurance. Please verify with your insurance provider that Dr. Cathryn Harbor is listed under your specific plan, and that testing by Quest Diagnostics is covered by your insurance. If you have questions while filling out this form, please return to the FAQ. If the answers to your questions are not there, please contact our office.

First Name

Last Name

Phone (xxx-xxx-xxxx)

General

I have read the FAQs

I understand the costs not covered by insurance

I understand Dr. Harbor's cancellation policy

Insurance Coverage (please select one)

I have verified that Dr. Cathryn Harbor is listed as a provider under my specific plan. If my insurance refuses to pay, I take responsibility for the bill

Cathryn Harbor is not a provider with my insurance plan. I will pay in full before my appointment. This payment of $500 will include the $250 chart review fee and the fee that Dr. Harbor would bill my insurance company for the visit, $250. I will be given a receipt to submit to my insurance.

I have not yet verified that Dr. Cathryn Harbor is a provider with my insurance plan. I will pay in full before my appointment. This payment of $500 will include the $250 chart review fee and the fee that Dr Harbor would bill my insurance company for the visit, $250. I will be given a receipt to submit to my insurance.

Testing (please select one)

I have verified that my insurance covers testing at Quest Diagnostics.

My Insurance does not cover testing at Quest Diagnostics. I agree to pay for necessary labs.

I plan to get my labwork done elsewhere and take responsibility for getting those results to Dr Harbor's office.