Name: ________________________________
DOB: _______________
MRN: ________________
(office use only)
GASTROENTEROLOGY ASSOCIATES OF THE PIEDMONT, PA
BILLING QUESTIONS: 336.714.3512 OR 336.714.3513 MONDAY – FRIDAY 8:00 AM - 4:30 PM
FINANCIAL POLICY
Both of our Endoscopy Centers have been granted a Certificate of Accreditation by the Accreditation Association for
Ambulatory Health Care (AAAHC). This certification recognizes our commitment to high quality care and substantial
compliance with the standards for ambulatory health care organizations. The Endoscopy Centers are considered to be
“Ambulatory Surgical Centers” or “ASC’s.” We have two locations to better serve our patients:
Salem Endoscopy Center
875 Bethesda Road
Winston-Salem, NC 27103
Piedmont Endoscopy Center
1901 South Hawthorne Road, Suite 308
Winston-Salem, NC 27103
1.
Payment is expected at the time of service unless other arrangements have been made in advance. Actual
reimbursement for charges will vary depending on your type of insurance coverage. Any co-payment, co-insurance or
deductible amounts will be collected at the time of your procedure. This is part of our contract with your insurance
company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud.
2.
We accept payment by cash, checks, money orders, Visa, MasterCard and Discover. You will receive a statement for any
remaining balance which is due upon receipt. A detailed statement is available upon request. Our office will charge a
$25 fee for all returned checks.
3.
Please contact our office for special payment arrangements.
4.
We will submit insurance claims on your behalf. Information needed to process your claim with your insurance company
should be received and verified prior to your appointment.
5.
Coverage for your procedure is determined by your contract with your insurance company. We recommend that you
contact your insurance company before receiving services.
6.
Your insurance may provide different coverage for a “screening” procedure versus a “diagnostic” procedure.
 A procedure is usually considered “screening” if you have no symptoms, biopsy or lesion removal.
 A procedure is considered “diagnostic” if you are having a problem or symptoms.
7.
You may incur charges for the following services related to your procedure:
Physician Fee  The fee for the physician performing your procedure.
Facility Fee
 The fee for the use of the facility for your procedure.
Pathology Fee  If a biopsy is required, you may incur a fee from Pathologists Diagnostic Services.
Anesthesia Fee  The fee for administration of anesthesia and monitoring of vital signs.
8.
The primary CPT procedure code(s) used for filing a claim with your insurance company are:
Colonoscopy—45378
Endoscopy—43235
9.
Depending on your insurance company, the location code associated with your procedure and facility charges can differ.
Listed below are the specific location codes corresponding with the major insurance companies with which G.A.P. is
considered a network provider.
Location 11 "Office Based"
Location 24 "Ambulatory Surgical Center/Outpatient"
Aetna
Cigna
Medicare
Blue Cross & Blue Shield
Coventry
Medicare Advantage Plans
MedCost
Tricare
Medicaid
United Healthcare
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Patient Signature
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Today’s Date
Revised 6/9/2015