ASC Procedure Instructions & Forms

Endoscopy - Billing Procedures for our ASC

**PLEASE READ THE FOLLOWING, SIGN THE BOTTOM AND BRING WITH YOU THE DAY OF YOUR PROCEDURE**

IF UNCLEAR, PLEASE CONTACT YOUR INSURANCE PLAN REGARDING YOUR INDIVIDUAL PLAN.

NOTE: THREE OR MORE SEPARATE CLAIMS WILL BE GENERATED FOR YOUR PROCEUDRE.

  1. The first claim will be generated for the services provided by your physician. This is the fee that the physician has charged you for doing the procedure. Please make arrangements to pay the portion that is not covered by your insurance company which may include copays, deductibles, and co-insurance.
  2. The second claim will be generated for the facility fee and takes the place of an outpatient hospital bill. The facility is state licensed and certified by Medicare as an Ambulatory Surgery Center. Your insurance company will be billed separately for these charges. Please make arrangements to pay the portion that is not covered by your insurance company which may include copays, deductibles, and co­ insurance.
  3. The third claim will be generated for anesthesia services provided. This is the fee that the anesthesia provider has charged you for providing deep sedation for your procedure. Please make arrangements to pay the portion that is not covered by your insurance company which may include copays, deductibles, and co-insurance.
  4. An additional claim(s) may he generated from a laboratory if a biopsy or specimen is taken during your procedure. Please make arrangements to pay the portion that is not covered by your insurance company which may include copays, deductibles, and co-insurance.

If you have any questions concerning your statements please contact the following:


Physician and/or facility fee
RCM Customer Service
Telephone: 443-933-4309
Fax: 443-933-4265

Anesthesia Services:
Telephone: 410-517-8030


I HAVE READ THE ABOVE AND I AM KNOWLEDGEABLE TO THE TERMS OF MY INSURANCE PLAN AS IT RELATES TO ANY COPAYS, DEDUCTIBLES AND/OR CO-INSURANCE.


Patient Name:
Patient Signature:
(name in corresponding box will act as signature)
Witness Signature:
(name in corresponding box will act as signature)