Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
Category: Patient Resources
Attention: Self-Pay Patients
(Patients who do not have any insurance coverage)
Payment is due at the time in which services are rendered. This includes co-pays, deductibles, co-insurance, and self-pay fees.
There is a minimum of $80.00 for an office visit.
Additional fees may be incurred due to tests or procedures performed at the visit.
Please let us know if you do not have insurance coverage and have questions regarding our policy.
Insurances We DO NOT File
**Always contact your insurance to verify that we are In Network, as it is ultimately your responsibility**
- We do not file any HMO policies unless they are a Medicare Advantage Plan or Healthkeepers.
- MEDICAID / MEDALLION (unless it’s Secondary to Medicare)
- VIRGINIA PREMIER
- CARENET (this is a form of Medicaid)
- OPTIMUM HEALTH (this CAN BE a form of Medicaid)
- OPTIMA HEALTH PLUS (we do participate with Optima Health, just not the PLUS policy)
- WELLPATH / COVENTRY ONE (this is a NC Medicaid Policy)
- Certain forms of Medcost Insurance will not pay for providers outside of North Carolina beginning 6/30/14. Please contact your benefits department with Medcost to determine whether or not this applies to you.
Returned Check Fee: $25.00
There is a $15.00 CHARGE for ALL FMLA FORMS & DISABILITY FORMS
Insurance & Fees
Become a Patient
To become a new patient, you will need to either contact the office OR fill out the form (attached) and return it to the office by mail, dropping it off, or email to S.Brinegar@mahoneymedicine.com. If you wish to fax it, please send to 276-403-5484